• Family Wellness Assessment Form

  • This form is designed to help families reflect on strengths and weaknesses in different areas of wellness. To begin, please tell us who you are.

  • Format: (000) 000-0000.

  • Family Wellness Assessment Form

  • Each section contains assessment questions with a 1–5 scale. Select the number that best represents your family’s current status. Add comments where appropriate.

  • Scale: 1 = Strongly Disagree | 2 = Disagree | 3 = Neutral | 4 = Agree | 5 = Strongly Agree

  • A. Physical Health

  • 1. Our family eats balanced meals regularly.*
  • 2. We participate in physical activity together.*
  • 3. We participate in physical activity together.*
  • 4. We attend regular health check-ups.*
  • 5. We limit excessive screen time and promote healthy habits.*

  • B. Emotional & Mental Health

  • 1. We encourage open expression of feelings.*
  • 2. Stress management strategies are practiced in our home.*
  • 3. We recognize and support each other's emotional needs.*
  • 4. Family members show resilience during challenges.*
  • 5. We celebrate successes and milestones together.*

  • C. Relationships

  • 1. Our family spends quality time together each week.*
  • 2. We show love, respect, and appreciation for one another.*
  • 3. Conflicts are resolved in a healthy and respectful way.*
  • 4. Each family member feels valued and included.*
  • 5. We support each other's goals and aspirations.*

  • D. Communication

  • 1. We practice active listening during conversation.*
  • 2. Everyone feels safe sharing their thoughts without judgement.*
  • 3. Important family decisions are made together.*
  • 4. Technology doesn't interfere with our communication.*
  • 5. We have regular family meetings or check-ins.*

  • E. Finances

  • 1. We budget and manage family expenses responsibly.*
  • 2. We save for emergencies and future needs.*
  • 3. Financial stress doesn't cause major conflict at home.*
  • 4. We teach children financial responsibilty.*
  • 5. Our family discusses financial goals openly.*

  • F. Spiritual & Community Wellness

  • 1. Our family practices faith or spiritual traditions together.*
  • 2. We encourage values such as kindness, honesty, and service.*
  • 3. Our family participates in community or volunteer activities.*
  • 4. Spiritual or moral principles guide our daily life.*
  • 5. We pray, reflect, or meditate as a family.*

  • Overall Family Wellness Reflection

  • Should be Empty: