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.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

3. My exercise program includes activities that build my heart, muscles and flexibility.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

4. I select lean cuts of meat, poultry or fish.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

5. I eat a variety of foods from all of the food groups.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

6. I eat breakfast.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

7. I get an adequate amount of sleep (7-8 hours per night.)

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

8. I examine my breasts or testes once a month

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

9. I participate in recommended periodic health screenings. (blood pressure,etc)

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

10. I seek medical advice when needed.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

11. I drink less than 5 alcoholic drinks at a setting.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

12. I avoid driving when under the influence of alcohol.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

13. I avoid using tobacco products.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

14. I minimize my exposure to second hand tobacco smoke.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

15. I keep my vehicle maintained to ensure safety.

n/a

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

16. When I see a safety hazard, I take steps to correct the problem.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

17. I choose an environment that is free of excessive noise, whenever possible.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

18. I make efforts to reduce, reuse and recycle.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

19. I try to create an environment that minimizes my stress.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

20. I make time for relaxation in my day.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

21. I make time in my day for prayer, meditation, or personal time.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

22. My values guide my actions and decisions.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

23. I am accepting of the views of others.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

24. I am able to sleep soundly throughout the night and wake feeling refreshed.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

25. I am able to make decisions with a minimum of stress and worry.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

26. I am able to set priorities.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

27. I maintain a balance between school, work and personal life.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

28. It is easy for me to apply knowledge from situation to another.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

29. I enjoy the amount and variety I read.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

30. I find life intellectually challenging and stimulating.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

31. I obtain health information from reputable sources.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

32. I spend money commensurate with my income, values and goals.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

33. I pay my bills in full each month (including my credit card. )

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

34. I am able to plan a manageable workload.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

35. My career is consistent with my values and goals.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

36. I plan time to be with my family and friends.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

37. I enjoy time with others.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

38. I am satisfied with the groups/organizations that I am a part of.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

39. My relationships with others are positive and rewarding.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

40. I explore diversity by interacting with people of other cultures, backgrounds and beliefs.

Never

Almost Never

Occasionally

Almost Always

Always

Clear selection

Thank you for taking this survey. We so appreciate YOU!

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