Wellbeing Self-Assessment

Wellbeing Self-Assessment 2.1
© CIT Clinics All rights reserved.

BEFORE YOU BEGIN...

What is being measured?

This assessment is designed to take a "snap shot" of the behaviors that contribute to your wellbeing over the past week/7 days. By limiting your responses to your behaviors for this past week/7 days you will be getting an accurate assessment of what you were actually doing and how you were actually feeling during this specific time period.

This past week/7 days was not a "typical" week for me. Will the results still be useful?

However "typical" or "atypical" this past week was for you, this self-assessment will give you an accurate measurement of your behaviors for this time period. Since our life circumstances are constantly changing, our behaviros and subjective sense of wellbeing, are constantly changing as well. We can only begin to understand our wellbeing if we take accurate measurements of our actual behaviors over time.

How often should I take the self-assessment?

We recommend that you take this self-assessment once per week (ideally on the same day each week) for several weeks. By repeating the self-assessment on a weekly basis you will begin seeing trends in your behaviors and be able to correlate your scores with specific behaviors that are either contributing or detracting from your wellbeing.

How many questions are there? How long will this take?

The self-assessment takes aproximately 5-7 minutes

How will I get my results?

Your results will be displayed on screen as well as sent to the email you enter.

What will you do with my results?

Your results and all information submitted are private and for your use only. We do NOT share, sell or transmit your results to anyone.

Today's Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Your Name*

First NameLast Name
First Name 2
Last Name 2
Email*
Mobile Phone Number
Date of Birth*

MonthDayYear

Physical Activity/Exercise
How would you rate your overall fitness right now?*

0

1

2

3

4

5

0 is Horrible, 5 is Awesome
In the past week, how motivated did you feel about working out/exercising?*

0

1

2

3

4

5

0 is Totally uninspired, 5 is Rocked it
How motivated are you to exercise today?*

0

1

2

3

4

5

0 is Ugh. No way, 5 is Bring it on!
In the past week, how many times did you exercise to the point of sweating and/or pushing yourself?*

0

1

2

3

4

5

0 is Never, 5 is 5 or more times
In the past week, how many times did you engage in strength training/weight lifting?*

0

1

2

3

4

5

0 is Never, 5 is 5 or more times
In the past week, how many times did you engage in stretching/flexibility training?*

0

1

2

3

4

5

0 is Never, 5 is 5 or more times
Nutrition & Eating
How would you rate your overall eating/nutrition habits this past week?*

0

1

2

3

4

5

0 is Horrible, 5 is Awesome
How consistent were you with your eating habits this past week?*

0

1

2

3

4

5

0 is All over the place, 5 is Perfectly consistent, all the time
In the past week, how often did you eat to the point of feeling full or stuffed?*

0

1

2

3

4

5

0 is Every day, 5 is Never
How much did you enjoy preparing/cooking your own food this past week?*

0

1

2

3

4

5

0 is I dreaded it, 5 is Total bliss
How would you rate your food preparation and cooking skills right now? *

0

1

2

3

4

5

0 is Terrible/ non existent, 5 is Expert chef
In the past week, how many meals did you prepare from basic ingredients (i.e. not pre-packed or frozen)?*

0

1

2

3

4

5

0 is None, 5 is All
In the past week, how many meals did you eat that were prepared by someone else (e.g. take out from a restaurant, prepared at a grocery store, etc.)?*

0

1

2

3

4

5

0 is All, 5 is None
Sleep
Overall, how would you rate your sleep this past week?*

0

1

2

3

4

5

0 is Horrible, 5 is Awesome
On average, how rested did you feel in the mornings?*

0

1

2

3

4

5

0 is Wrecked, 5 is Sparkly; bright
On average, how many hours per night did you sleep this past week?*

Fewer than 4 hours45678 or more hours per night
In the past week, how often did you have trouble falling asleep?*

0

1

2

3

4

5

0 is Every night, 5 is Never
In the past week, how often did you have trouble staying asleep?*

0

1

2

3

4

5

0 is Every night, 5 is Never
How often did you take something (prescriptions, OTC, herbal supplements, etc.) to help yourself sleep?*

0

1

2

3

4

5

0 is Every night, 5 is Never
In the past week, how often did you wake up with an alarm?*

0

1

2

3

4

5

0 is Every morning, 5 is Never
In order to become awake/alert this last week, how frequently did you drink caffeine or other stimulants?*

0

1

2

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5

0 is Every morning, 5 is Never
Cognitive & Intellectual
In the past week, how often did you read a book (hardcopy and/or tablet)?*

0

1

2

3

4

5

0 is Never, 5 is Daily
How mentally sharp/quick/clear did you feel this past week?*

0

1

2

3

4

5

0 is Total brain fog, 5 is Genius
How often did you feel intellectually challenged this past week?*

0

1

2

3

4

5

0 is Not at all, 5 is Daily
How often were you engaged in interesting conversations this past week?*

0

1

2

3

4

5

0 is None, 5 is Daily
Did you learn anything new/interesting/practical this past week?*

0

1

2

3

4

5

0 is Nope, 5 is Yes, tons
How often did you procrastinate this past week?*

0

1

2

3

4

5

0 is All the time, 5 is Never
How was your concentration this past week?*

0

1

2

3

4

5

0 is Scattered, 5 is Razor sharp
Emotional & Mood
How happy and cheerful did you feel this past week?*

0

1

2

3

4

5

0 is Hopeless & depressed, 5 is Giddy
How much did you struggle with perfectionism this past week?*

0

1

2

3

4

5

0 is All the time, 5 is Never
How often did you experience shame last week?*

0

1

2

3

4

5

0 is Way too much, 5 is Not once
How frequently did you experience despair this past week?*

0

1

2

3

4

5

0 is Way too often, 5 is Never
How frequently did you experience joy this past week?*

0

1

2

3

4

5

0 is Never, 5 is All the time
How frequently did you experience gratitude this past week?*

0

1

2

3

4

5

0 is Never, 5 is All the time
How often did you laugh out loud this past week?*

0

1

2

3

4

5

0 is Never, 5 is Constantly
How frequently did you experience awe this past week?*

0

1

2

3

4

5

0 is Not once, 5 is All the time
How often did you experience fear this past week?*

0

1

2

3

4

5

0 is Daily, 5 is Not once
Stress Management
Overall, how stressed were you this past week?*

0

1

2

3

4

5

0 is Max'd out, 5 is Totally chill
How well are you coping with stress in this moment?*

0

1

2

3

4

5

0 is Flailing, 5 is Like a champ
How were your anxiety levels this past week?*

0

1

2

3

4

5

0 is Extreme, 5 is Nonexistent
How much fun did you have this past week?*

0

1

2

3

4

5

0 is None, 5 is Tons
How frequently did you have interactions with other people that felt stressful to you in the past week?*

0

1

2

3

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5

0 is Daily, 5 is Never
How emotionally resilient did you feel this past week?*

0

1

2

3

4

5

0 is Thin skinned, 5 is Solid, like a rock
How satisfied do you feel about your stress management skills this past week?*

0

1

2

3

4

5

0 is Ugh. Awful, 5 is Rocked it
Overall, how much control do you have to change/influence situations that you find stressful?*

0

1

2

3

4

5

0 is None/ powerless, 5 is Total control
Physical Health
How physically energetic/vital did you feel this past week?*

0

1

2

3

4

5

0 is Exhausted, 5 is Like a super star
How frequently did you experience persistent pain, soreness, stiffness, aching, etc. this past week?*

0

1

2

3

4

5

0 is Every day, 5 is Never
How would you rate your bowel movements in the past week?*

0

1

2

3

4

5

0 is Awful - blocked or diarrhea, 5 is Excellent - good texture; easy to pass
How sexually satisfied did you feel this past week?*

0

1

2

3

4

5

0 is Not at all, 5 is Extremely
In the last week, how often did you take medication (includes OTC and/or Rx) for pain?*

0

1

2

3

4

5

0 is Daily, 5 is Never
How often was the color of your urine pale yellow or lighter this past week?*

0

1

2

3

4

5

0 is Never, 5 is 5 or more days
How often did you feel tired/fatigued this past week?*

0

1

2

3

4

5

0 is Daily, 5 is Never
Self-Care
How would you rate your self-care skills in this moment?*

0

1

2

3

4

5

0 is Terrible, 5 is Awesome
How often did you go for a walk/spend time in nature last week?*

0

1

2

3

4

5

0 is Never, 5 is Daily
How often did you check work email or do other work-related activities within 1-2 hours of bedtime?*

0

1

2

3

4

5

0 is Every night, 5 is Not at all
How much time did you spend watching TV and/or online entertainment last week?*

0

1

2

3

4

5

0 is All the time, 5 is Once in a while
How much time did you spend watching the news/current events last week?*

0

1

2

3

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5

0 is All the time, 5 is Once in a while
In the past week, how much time did you spend on social media?*

0

1

2

3

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5

0 is All the time, 5 is Once in a while
How often did you meditate or practice other forms of personal reflection this past week?*

0

1

2

3

4

5

0 is Never, 5 is Daily
How did you handle your schedule, time use, and overall busy-ness last week?*

0

1

2

3

4

5

0 is Panicked, 5 is Totally calm & relaxed
How frequently did you engage in hobbies/non-work-related activities last week?*

0

1

2

3

4

5

0 is Never, 5 is Daily
How well did you balance work and leisure time last week?*

0

1

2

3

4

5

0 is Terrible, 5 is Perfection
This past week, how frequently did you engage in activities that you did NOT enjoy?*

0

1

2

3

4

5

0 is Daily, 5 is Not once
How satisfied are you with the amount of time you took for yourself this past week?*

0

1

2

3

4

5

0 is Dissatisfied, 5 is Totally satisfied
Work
How many hours did you work this past week (for self and/or employer)?*

I did not workFewer than 10 hours10-20 hours20-30 hours30-40 hours40-50 hours50 or more hours
How much did you enjoy your work last week? (leave blank if you did not work)

0

1

2

3

4

5

0 is Awful, 5 is Blissed out
How meaningful was your work this past week? (leave blank if you did not work)

0

1

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5

0 is Pointless, 5 is Very significant
How would you rate the quality of connection you had with your coworkers? (leave blank if you did not work)

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5

0 is Terrible, 5 is Blissful
How respected/understood did you feel by your coworkers? (leave blank if you did not work)

0

1

2

3

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5

0 is Invisible, 5 is Totally gotten
How stressful was your work this past week? (leave blank if you did not work)

0

1

2

3

4

5

0 is Off the charts, 5 is Totally chill
How capable/competent did you feel about your work this past week? (leave blank if you did not work)

0

1

2

3

4

5

0 is Clueless, 5 is Total pro
Social & Relational
How would you rate the interaction with your friends and family this past week?*

0

1

2

3

4

5

0 is Toxic, 5 is Harmonious/ blissful
Right now, how much do the people around you support your health, fitness, and/or behavior change?*

0

1

2

3

4

5

0 is Not at all, 5 is Completely
In the past week, how was the quality of connection with your neighbors/community?*

0

1

2

3

4

5

0 is Toxic, 5 is Harmonious/ blissful
How often did you express love and gratitude to your family/friends last week?*

0

1

2

3

4

5

0 is Never, 5 is Daily
In the past week, how often did your family/friends express love and gratitude to you?*

0

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2

3

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5

0 is Never, 5 is Daily
In the past week, how often did you eat/share meals with family/friends?*

0

1

2

3

4

5

0 is Never, 5 is Daily
In the past week, how frequently did you feel stressed by the people around you?*

0

1

2

3

4

5

0 is Constantly, 5 is Never
How often did you feel lonely last week?*

0

1

2

3

4

5

0 is All the time, 5 is Never
How comfortable did you feel about being vulnerable and transparent with your family and friends last week?*

0

1

2

3

4

5

0 is Never, 5 is All the time
Structure & Support
In this moment, how clear are you about the changes you need to make in order to feel content and healthy?*

0

1

2

3

4

5

0 is Not at all clear, 5 is Extremely clear
At this time, how clear are you about which specific behaviors, practices and skills will best support your ongoing wellbeing?*

0

1

2

3

4

5

0 is Unclear, 5 is Crystal clear
At this time, do you have a clear plan to attain your wellbeing goals over the next 3 months?*

0

1

2

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5

0 is I don't have a plan, 5 is I have a detailed road map
In this moment, how hopeful do you feel that you will be able to make meaningful and lasting changes to your wellbeing over the coming weeks/months?*

0

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2

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5

0 is Not hopeful, 5 is Extremely hopeful
In this moment, how confident do you feel that you have the professional support you need to make lasting changes in your life?*

0

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5

0 is I feel very alone, 5 is I have all the support I need
In this past week, how optimistic were you that if you keep trying you will feel healthier and happier one year from now?*

0

1

2

3

4

5

0 is Very pessimistic, 5 is Extremely optimistic
In this past week, how satisfied were you with your efforts to make meaningful changes in your life?*

0

1

2

3

4

5

0 is Disappointed/frustrated, 5 is Thrilled
Grand Total Max
Grand Total Score
Grand Total Percent
Physical Activity/Exercise Percent
Nutrition/Eating Percent
Sleep Score Percent
Cognitive/Intellectual Percent
Stress Management Percent
Emotional/Mood Percent
Physical Health Percent
Self Care Percent
Work Percent
Family & Community Percent
Structure & Support Percent
Physical Activity Max
Physical Activity/Exercise Score
Nutrition/Eating Max
Nutrition/Eating Score
Sleep Max
Sleep Score
Cognitive/Intellectual Max
Cognitive/Intellectual Score
Emotional/Mood Max
Emotional/Mood Score
Stress Management Max
Stress Management Score
Physical Health Max
Physical Health Score
Self Care Max
Self Care Score
Work Max
Work Score
Family & Community Max
Family & Community Score
Structure & Support Max
Structure & Support Score
Lead Status
Lead Source
kw_email_list
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Wellbeing Self-Assessment 2.1

BEFORE YOU BEGIN...

What is being measured?

This past week/7 days was not a "typical" week for me. Will the results still be useful?

How often should I take the self-assessment?

How many questions are there? How long will this take?

How will I get my results?

What will you do with my results?

Physical Activity/Exercise

Nutrition & Eating

Sleep

Cognitive & Intellectual

Emotional & Mood

Stress Management

Physical Health

Self-Care

Work

Social & Relational

Structure & Support