The purpose of this survey is to indicate areas of wellness practice and opportunity for improvement. Individual data is confidential and will be shared only with you. By completing this in monthly and quarterly intervals, goals can be set and recommendations made. Progress and challenges be noted and discussed across time. Your daily practice will influence how you feel, age and manage chronic mental and physical health issues.
Indicate the appropriate number on all questions below. Please answer all questions based on your recent experience. Excellence is defined as practicing with age-appropriate skill and attentiveness.
0 – little or no wellness practice
1 – wellness practice one to two times per week; low excellence
2 – wellness practice three to four times per week: moderate excellence
3 – wellness practice five to seven times per week; high excellence