Individual Life Balance Survey (ILBS)
Please fill out the Personal Information section before your start so we can contact you for feedbacks. Make sure your response are as accurate as it can be so the feedbacks will be most pertinent and helpful to you.
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Email Address: *
Sex *
Required
Date of Birth: *
Month Day Year
Educaltion *
Degree obtained or in years
Occupation *
Part I - Your Current Situation
Please indicate how much each condition affect you on a 0-6 point scale
1. Arthritis *
Not at all
Severely
2. Coronary Heart diseases (heart attacks or strokes) *
Not at all
Severely
3. Cancer (e.g.,breast and colon cancer) *
Not at all
Severely
4. Diabetes *
Not at all
Severely
5. Epilepsy and seizures *
Not at all
Severely
6. Obesity *
Not at all
Severely
7. Other chronic condition ___________________ *
Not at all
Severely
8. Sleep disturbance (falling, staying, wake up often, wake up too early) *
Not at all
Severely
9. Eating disorder (anorexia, binging or purging) *
Not at all
Severely
10. High blood pressure *
Not at all
Severely
11. High cholesterol *
Not at all
Severely
12. Frequent cough or wheeze *
Not at all
Severely
13. Frequent colds, sinus infections or bronchitis *
Not at all
Severely
14. Heartburn or frequent burp *
Not at all
Severely
15. Diarrhea or constipation *
Not at all
Severely
16. Headaches or dizziness *
Not at all
Severely
17. Difficulty with balance and fall a lot *
Not at all
Severely
18. Unusual lumps, bumps, marks, or moles on the skin *
Not at all
Severely
19. Sores in the mouth and/or swollen/bleeding gums *
Not at all
Severely
20. Pain or discomfort in eyes *
Not at all
Severely
21. Hearing problem, ear pain or discomfort *
Not at all
Severely
22. Joint or muscle pain or stiffness *
Not at all
Severely
23. Difficulty getting around *
Not at all
Severely
24. Pain or difficulty urinating *
Not at all
Severely
25. Bladder or kidney infections *
Not at all
Severely
26. Pain or problems during period (menstruation) *
Not at all
Severely
27. Other symptoms __________________ *
Not at all
Severely
28. Memory problem *
Not at all
Severely
29. Difficulty concentrating and focus *
Not at all
Severely
30. Hyperactive and restless *
Not at all
Severely
31. Anxious and panic attacks *
Not at all
Severely
32. Worrying a lot *
Not at all
Severely
33. Mood swings *
Not at all
Severely
34. Very sad and depressed *
Not at all
Severely
35. Irritable, agitated, and unable to relax *
Not at all
Severely
36. Hearing or seeing things that are not there *
Not at all
Severely
37. Strange or bizarre thoughts and or beliefs *
Not at all
Severely
38. Thought blocking *
Not at all
Severely
39. Difficulty organizing thoughts *
Not at all
Severely
40. Racing thoughts *
Not at all
Severely
41. Ruminating or obsessive thoughts *
Not at all
Severely
42. Difficulty starting desired behaviors/actions *
Not at all
Severely
43. Difficulty controlling actions *
Not at all
Severely
Please indicate how true each of the following statements for you on an 0 -6 scale
44. I am very close to my family *
Not True at all
Completely True
45. I am very satisfied about my relationship with my family *
Not true at all
Completely True
46. I am very attached to the person I am in an intimate relationship *
Not true at all
Completely true
47. I am satisfied with my level of intimacy with my partner *
Not true at all
Completely true
48. I have friends and I keep frequent contact with them *
Not true at all
Completely true
49. I am satisfied with the level of friendships in my life *
Not true at all
Complete true
50. I have pets *
Not true at all
Completely true
51. I am satisfied with the friendship and companionship I get from pets *
Not true at all
Completely true
52. I take an active role in at least one social group/organization that I am part of *
Not true at all
Completely True
53. I am satisfied with the role I play in social groups/organizations *
Not true at all
Completely true
54. I have a relationship with God (or other religious entity) *
Not true at all
Completely true
55. I am satisfied with my religious connection *
Not true at all
Completely true
56. I spend a lot of time doing things I love and enjoy *
Not true at all
Completely true
57. I have abilities and talents that I am proud of *
Not true at all
Completely true
58. The works I do allow expression of my interests and skills *
Not true at all
Completely true
59. I have hobbies that make my life exciting and enjoyable *
Not true at all
Completely true
60. I am very satisfied with the level of my skills and abilities *
Not true at all
Completely true
61. I make my own decisions and am in control of where my life is going *
Not true at all
Completely true
62. I am not dependent on anyone emotionally *
Not True at all
Completely true
63. I don't depend on anyone financially *
Not true at all
Completely true
64. I have a sense of purpose and direction in life *
Not true at all
Completely true
65. I have achieved a sense of inner peace *
Not true at all
Completely true
66. My life is filled with happiness and joy *
Not true at all
Completely true
Part II - Your Thoughts, Beliefs, and Values
Please rate the following statement on a 0-6 scale with 0 means "Disagree Completely" and 6 means "Agree completely"
1. I am often too busy to worry about my health *
Disagree completely
Agree completely
2. Staying healthy is an ongoing investment *
Disagree completely
Agree completely
3. Stress is a under recognized and dangerous health hazard *
Disagree completely
Agree completely
4. One's health depends on one's lifestyle choices *
Disagree completely
Agree completely
5. Many diseases can be prevented by living a healthy lifestyle *
Disagree completely
Agree completely
6. Psychological problems can be corrected and/or controlled *
Disagree completely
Agree completely
7. It's a shame and embarrassment to have psychological problems *
Disagree completely
Agree completely
8. One is not to blame but is responsible for overcoming psychological problems *
Disagree completely
Agree completely
9. Bad or traumatic experiences in early life negatively affect one's psychological functioning *
Disagree completely
Agree completely
10. One should take control of one's mental health by finding effective solutions or coping strategies *
Disagree completely
Agree completely
11. Avoiding and ignoring mental problem will make it worse in the future *
Disagree completely
Agree completely
12. People often underestimate the negative consequences of mental problems *
Disagree completely
Agree completely
13. It's a weakness to seek help for psychological problems *
Disagree completely
Agree completely
14. Life would be without purpose and meaning if people don't like and care about me *
Disagree completely
Agree completely
15. In a good relationship one should be always happy and content *
Disagree completely
Agree completely
16. Friendships should be an essential part of everyone's life *
Disagree completely
Agree completely
17. It is essential for everyone to be in an intimate relationship *
Disagree completely
Agree completely
18. Animals or pets are the most reliable human companions or friends *
Disagree completely
Agree completely
19. It is essential for any human being to belong to a social group or organization *
Disagree completely
Agree completely
20. One should not trust others for anything *
Disagree completely
Agree completely
21. Nobody should change for anyone else *
Disagree completely
Agree completely
22. Family is an essential part of everyone's life wherever your are and whatever you do *
Disagree completely