Wellness Survey
Please fill out the following multiple choice question. Pick only one response per question.
1. Peer Number:
2. I exercise for 30 minutes or more most days of the week.
Clear selection
3. My exercise program includes activities that build my heart, muscles and flexibility.
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4. I select lean cuts of meat, poultry or fish.
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5. I eat a variety of foods from all of the food groups.
Clear selection
6. I eat breakfast.
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7. I get an adequate amount of sleep (7-8 hours per night.)
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8. I examine my breasts or testes once a month
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9. I participate in recommended periodic health screenings. (blood pressure,etc)
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10. I seek medical advice when needed.
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11. I drink less than 5 alcoholic drinks at a setting.
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12. I avoid driving when under the influence of alcohol.
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13. I avoid using tobacco products.
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14. I minimize my exposure to second hand tobacco smoke.
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15. I keep my vehicle maintained to ensure safety.
Clear selection
16. When I see a safety hazard, I take steps to correct the problem.
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17. I choose an environment that is free of excessive noise, whenever possible.
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18. I make efforts to reduce, reuse and recycle.
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19. I try to create an environment that minimizes my stress.
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20. I make time for relaxation in my day.
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21. I make time in my day for prayer, meditation, or personal time.
Clear selection
22. My values guide my actions and decisions.
Clear selection
23. I am accepting of the views of others.
Clear selection
24. I am able to sleep soundly throughout the night and wake feeling refreshed.
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25. I am able to make decisions with a minimum of stress and worry.
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26. I am able to set priorities.
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27. I maintain a balance between school, work and personal life.
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28. It is easy for me to apply knowledge from situation to another.
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29. I enjoy the amount and variety I read.
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30. I find life intellectually challenging and stimulating.
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31. I obtain health information from reputable sources.
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32. I spend money commensurate with my income, values and goals.
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33. I pay my bills in full each month (including my credit card. )
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34. I am able to plan a manageable workload.
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35. My career is consistent with my values and goals.
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36. I plan time to be with my family and friends.
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37. I enjoy time with others.
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38. I am satisfied with the groups/organizations that I am a part of.
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39. My relationships with others are positive and rewarding.
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40. I explore diversity by interacting with people of other cultures, backgrounds and beliefs.
Clear selection
Thank you for taking this survey. We so appreciate YOU!
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