Wellness Assessment
This is a survey not a test, there is no wrong answer. Please take your time and answer as honestly as you can. Answers are confidential. Thank you for helping us to help you.
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Peer # *
Your answer
Date *
Year of Birth
Your answer
Your answer
Your answer
Your answer
How do you feel today
Your answer
Is this your 1st, 2nd, or 3rd time taking this survey? *
2. I exercise for 30 minutes or more most days of the week. *
3. My exercise program includes activities that build my heart, muscles and flexibility. *
4. I select lean cuts of meat, poultry or fish. *
5. I eat a variety of foods from all of the food groups. *
6. I eat breakfast. *
7. I get an adequate amount of sleep (7­-8 hours per night). *
8. I examine my breasts or testes once a month. *
9. I participate in recommended periodic health screenings (blood pressure, etc.). *
10. I seek medical advice when needed. *
11. I drink less than 5 alcoholic drinks at a setting. *
12. I avoid driving when under the influence of alcohol. *
13. I avoid using tobacco products. *
14. I minimize my exposure to second hand tobacco smoke. *
15. I keep my vehicle maintained to ensure safety. *
16. When I see a safety hazard, I take steps to correct the problem. *
17. I choose an environment that is free of excessive noise, whenever possible. *
18. I make efforts to reduce, reuse and recycle. *
19. I try to create an environment that minimizes my stress. *
20. I make time for relaxation in my day. *
21. I make time in my day for prayer, meditation, or personal time.
22. My values guide my actions and decisions.
23. I am accepting of the views of others.
24. I am able to sleep soundly throughout the night and wake feeling refreshed.
25. I am able to make decisions with a minimum of stress and worry.
26. I am able to set priorities.
27. I maintain a balance between school, work and personal life.
28. It is easy for me to apply knowledge from one situation to another.
29. I enjoy the amount and variety I read.
30. I find life intellectually challenging and stimulating.
31. I obtain health information from reputable sources.
32. I spend money commensurate with my income, values and goals.
33. I pay my bills in full each month (including my credit card).
34. I am able to plan a manageable workload.
35. My career is consistent with my values and goals.
36. I plan time to be with my family and friends.
37. I enjoy my time with others.
38. I am satisfied with the groups/organizations that I am a part of.
39. My relationships with others are positive and rewarding
40. I explore diversity by interacting with people of other cultures, backgrounds and beliefs.
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