image
Health and Wellness Survey
This survey is meant as a guide to be part of an assessment process. Please answer the following questions as open and honest as possible.
In general, would you say your health is:
Excellent
Very Good
Good
Fair
Poor
I am able to pinpoint situations that cause me stress.
Always True
Frequently True
Seldom True
Never True
I avoid eating foods that are high in calories and fat.
Please indicate the activities in which you participate that help you relieve stress.
Exercise
Yes
No
Eat Right
Deep breathing
Read a book
Listen to music
Take a walk/hike
Play sports
How often during the past 2 weeks did you:
Get the amount of sleep you needed
All of the time
Most of the time
Some of the time
None of the time
Have trouble falling asleep at night
Wake up unexpectedly during the night
Have difficulties staying awake during the day