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 *
MM
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DD
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YYYY
Year of Birth
Your answer
Race
Your answer
Gender
Your answer
Employed
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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