2010 HFHS Stress and Pain Free Living Eligibility Questionnaire

For Henry Ford Health System (HFHS) employees, their family members at least 18 years of age, and HFHS retirees


Hello and congratulations on choosing to complete the following confidential questionnaire, which is required prior to entering the program. I acknowledge you for your commitment to improving and optimizing your health. This program is free to eligible Henry Ford Health System employees, their family members at least 18 years of age, and HFHS retirees.

 

Prior to entering the program, this is the only survey you will complete. We ask you to complete this so that we can best understand each and every person’s health challenges and ensure that our program contents are best addressing the needs of all participants. I thank you in advance for your thoughtful participation and for providing complete and accurate information, all of which is kept strictly secure and private. Your individual information is not shared with anyone, including other family members or individuals who are related to your employment. 

 

By offering this program as a research study, we are able to publish results of the program, which helps raise awareness of program benefits and supports more people in need having access to the program. The program has proven in most participants to reduce or eliminate chronic pain and medication use, relieve stress, decrease depressive feelings, reduce disability, and improve sleep quality, among other benefits. Of course, there is no guarantee that you will get these results, however it is surely possible. Thank you for partnering with us!

The survey typically takes between 15 and 25 minutes to complete. If you can't finish the survey in one sitting, you can save it and pick up where you left off later. Just make sure you click the "Save" button, then document the link it gives you (e.g. write it down on a piece of paper or copy-paste to a Word file on your computer) and use that personalized link to access the survey next time.

 
You will be contacted soon after you finish the survey with more information about the program. The program will be offered starting this fall at several locations throughout the Detroit metro area, so it is likely you will find a time and location that works for you.

 

Thank you for your interest! If you have any problems with the survey, please contact Ron Ball at the Henry Ford Center for Integrative Wellness at rball1@hfhs.org or 248-386-5353


To your optimal health and wellness,   

 

Dr. Bob

To Your Optimal Health and Wellness!

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Robert A. Levine, Ph.D., C.Ht., Director

Center for Integrative Wellness, and

     Integrative Wellness Research

Henry Ford Health System- Southfield Medical Center

22777 West Eleven Mile Road

Southfield, MI 48033-2152

Phone: (248) 342-7555   FAX: (206) 666-2803

bob@drboblevine.com; HFHS email: rlevine1@hfhs.org

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First name
Middle name (if you do not have one, please leave blank)
Last name

Email address

Verify email address



For phone numbers below, please fill in all that apply. Leave blank if there are any boxes for which you have no answer. Thank you for providing this information, it helps us keep in contact with you throughout the program.

Format for phone numbers below: xxx-xxx-xxxx
Home phone number
Work phone number
Cell phone number

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