Wellbeing Questionnaire

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Following are four broad areas of possible change:

Exercise, Nutrition, Energy/Sleep and Stress Management.

Please think about what is really important to you when answering the questions.

Email *

Record my email address with my response

Exercise

Are you currently exercising regularly?

Yes

Clear selection

I am happy with my current level of activity.

Yes

Clear selection

Readiness for Change: On a scale of 1 to 10 (1=Not, 10= Very)

How important is it that you make changes or improvements in your level of exercise at this time?

Clear selection

Readiness for Change: On a scale of 1 to 10 (1=Not, 10= Very)

How confident are you that you can make change or improvements in your level of exercise at this time?

Clear selection

Nutrition

I feel I generally follow good nutritional habits.

Yes

Clear selection

I feel I have adequate knowledge to make good nutritional choices for my stage of life.

Yes

Clear selection

Readiness for Change: On a scale of 1 to 10 (1=Not, 10= Very)

How important is it that you make changes or improvements in your nutrition at this time?

Clear selection

Readiness for Change: On a scale of 1 to 10 (1=Not, 10= Very)

How confident are you that you can make change or improvements in your nutrition at this time?

Clear selection

Sleep

I get 7-8 hours of quality sleep at night

Often

Sometimes

Rarely

Clear selection

I have a regular pattern of sleep and practice good sleep hygiene.

Often

Sometimes

Rarely

Clear selection

Readiness for Change: On a scale of 1 to 10 (1=Not, 10= Very)

How important is it that you make changes or improvements in your sleep at this time?

Clear selection

Readiness for Change: On a scale of 1 to 10 (1=Not, 10= Very)

How confident are you that you can make change or improvements in your sleep at this time?

Clear selection

Stress Management

I feel calm and peaceful and manage with my current stress level well.

Sometimes

Often

Rarely

Clear selection

I am unable to stop thinking about my problems.

Sometimes

Often

Rarely

Clear selection

Readiness for Change: On a scale of 1 to 10 (1=Not, 10= Very)

How important is it that you make changes or improvements in your stress level at this time?

Clear selection

Readiness for Change: On a scale of 1 to 10 (1=Not, 10= Very)

How confident are you that you can make change or improvements in your level of stress at this time?

Clear selection

A copy of your responses will be emailed to .

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