Wellness of Self-Assessment
Participant Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
1. I exercise for 30 minutes or more most days of the week.
Never
Almost Never
Occasionally
Almost Always
Always
2. My exercise program includes activities to build my heart, muscles and flexibility.
Never
Almost Never
Occasionally
Almost Always
Always
3. I select lean cuts of meat, poultry or fish.
Never
Almost Never
Occasionally
Almost Always
Always
4. I eat a variety of foods from all the food groups.
Never
Almost Never
Occasionally
Almost Always
Always
5. I eat breakfast.
Never
Almost Never
Occasionally
Almost Always
Always
5. I get an adequate amount of sleep (7-8 hrs per night)
Never
Almost Never
Occasionally
Almost Always
Always
6. I examine my breast or testes once a month.
Never
Almost Never
Occasionally
Almost Always
Always
8. I participate in recommended periodic health screenings.
Never
Almost Never
Occasionally
Almost Always
Always
9. I seek medical advice when needed
Never
Almost Never
Occasionally
Almost Always
Always
10. I drink less than 5 alcoholic drinks at a setting.
Never
Almost Never
Occasionally
Almost Always
Always
11. I avoid driving while under the influence of alcohol.
Never
Almost Never
Occasionally
Almost Always
Always
12. I avoid using tobacco products.
Never
Almost Never
Occasionally
Almost Always
Always
13. I minimize my exposure to secondhand tobacco smoke.
Never
Almost Never
Occasionally
Almost Always
Always
14. I keep my vehicle maintained to ensure safety.
Never
Almost Never
Occasionally
Almost Always
Always
14. I keep my vehicle maintained to ensure safety.
Never
Almost Never
Occasionally
Almost Always
Always
15. When I see a safety hazard, I take steps to correct the problem.
Never
Almost Never
Occasionally
Almost Always
Always
16. I choose an environment that is free of excessive noise whenever possible.
Never
Almost Never
Occasionally
Almost Always
Always
17. I make efforts to reduce, reuse and recycle.
Never
Almost Never
Occasionally
Almost Always
Always
18. I try to create an environment that minimizes my stress.
Never
Almost Never
Occasionally
Almost Always
Always
19. I make time for relaxation in my day.
Never
Almost Never
Occasionally
Almost Always
Always
20. I make time in my day for prayer, meditation, or personal time.
Never
Almost Never
Occasionally
Almost Always
Always
21. My values guide my actions and decisions.
Never
Almost Never
Occasionally
Almost Always
Always
22. I am accepting of the views of others
Never
Almost Never
Occasionally
Almost Always
Always
23. I am able to sleep soundly throughout the night and wake feeling refreshed.
Never
Almost Never
Occasionally
Almost Always
Always
24. I am able to make decisions with a minimum of stress and worry.
Never
Almost Never
Occasionally
Almost Always
Always
25. I am able to set priorities.
Never
Almost Never
Occasionally
Almost Always
Always
26. I maintain a balance between work, school and personal life.
Never
Almost Never
Occasionally
Almost Always
Always
27. It is easy for me to apply knowledge from one situation to another.
Never
Almost Never
Occasionally
Almost Always
Always
28. I enjoy the amount and the variety I read.
Never
Almost Never
Occasionally
Almost Always
Always
29. I find life intellectually challenging and stimulating.
Never
Almost Never
Occasionally
Almost Always
Always
30. I obtain Health information from reputable sources.
Never
Almost Never
Occasionally
Almost Always
Always
31. I spend money commensurate with my income, values and goals.
Never
Almost Never
Occasionally
Almost Always
Always
32. I pay my bills in full each month including my credit card.
Never
Almost Never
Occasionally
Almost Always
Always
33. I am able to plan a manageable workload.
Never
Almost Never
Occasionally
Almost Always
Always
34. My career is consistent with my values and goals.
Never
Almost Never
Occasionally
Almost Always
Always
35. I plan time to be with my family and friends.
Never
Almost Never
Occasionally
Almost Always
Always
36. I enjoy my time with others.
Never
Almost Never
Occasionally
Almost Always
Always
37. I am satisfied with the groups/organizations that I am part of.
Never
Almost Never
Occasionally
Almost Always
Always
38. My relationships with others are positive and rewarding.
Never
Almost Never
Occasionally
Almost Always
Always
39. I explore diversity by interacting with people of other cultures and beliefs.
Never
Almost Never
Occasionally
Almost Always
Always
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