Personal Wellness Assessment Form

Full Name
First NameLast Name
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com

Emotional

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I find healthy ways to cope with stress (e.g. exercise, meditation, social support, self-care activities, etc.)
I am able to ask for assistance when I need it, either from friends and family, or professionals.
I accept responsibility for my own actions.
I am able to set priorities.
I feel good about myself and believe others like me for who I am.
I am flexible and able to adapt/adjust to life’s changes in a positive way.
I can express all ranges of feelings (i.e. hurt, sadness, fear, anger, joy, etc.) and manage emotion-related behaviors in a healthy way.
I maintain a balance of work, friends, family, school and other obligations.
I do not let my emotions get the better of me. I think before I act.

SPIRITUAL

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I take time to think about what is important in life – who I am, what I value, where I fit in, where I’m going.
I make time for relaxation during the day.
I have a belief system in place (religious, agnostic, atheist, spiritual, etc.).
My values guide my decisions and actions.
I have a sense of purpose in my life.
I am tolerant and accepting of the view of others.
I utilize resources to improve my well-being.
I am active in communities or causes I care about.
I am able to set, communicate and enforce boundaries.
I work to create balance and peace within my interpersonal relationships, community and the world.

PHYSICAL

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I manage my weight in healthy ways.
I exercise regularly.
I get 7-9 hours of sleep each night and feel rested in the morning.
I seek advice from health care professionals if I have a health concern I cannot solve on my own.
I do not use or avoid harmful use of drugs (over-the-counter, prescription and illicit).
I drink alcohol responsibly (i.e. designated sober driver, avoid binge drinking, etc.)
I protect my skin from sun damage by using sunscreen with SPF 30+, wearing hats and/or avoiding tanning booths and sun lamps.
I maintain healthy eating patterns that include fruits and vegetables.
I stay hydrated and drink water throughout the day.
I protect myself from STIs and unwanted pregnancy by either abstaining from sexual behaviors or using proper protection, such as condoms.

SOSIAL

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I am satisfied with my social life.
I am involved in at least one university community or group.
I maintain a network of supportive friends, family and social contacts.
I have at least one meaningful relationship in my life.
I am accepting of the diversity of others (race, ethnicity, religion, gender, ability, sexual orientation, etc.)
I am able to prioritize my own needs by saying “no” to others’ requests for my time.
I have someone I can talk to about my feelings and struggles.
I participate in social activities and enjoy being with people who are different from me.
I give and take equally in my relationships.
I plan time with my family and friends.

FINANCIAL

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I am able to set and stick to a budget each month so I don’t run out of money.
I know my total amount of debt and interest rates.
I pay my credit cards, tuition/fees and other bills on time.
I know about the different sources of financial aid that I am eligible for and apply when I am able.
I have a savings account and save money regularly.
I know my credit score.
I keep my financial information safe by using secure passwords, PINs and dual authentication.
I feel good about my current and future financial situation.
I check my bank statements/accounts each month.
I understand how to build credit and use credit cards wisely.

OCCUPATIONAL

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I am able to balance work, play, school and other aspects of my life.
I take advantage of opportunities to learn new skills that can enhance my future employment opportunities.
I know what skills are necessary for the occupations I am interested in.
I strive to develop good work habits (dependability, initiative, etc.).
I work effectively with others.
I have confidence in my job search skill (resume writing, interviewing, cover letters, networking, etc.).
I have explored different career options.
I know where to find employment opportunities (job service, online, etc.)
I manage my time effectively.
I have participated in internships or volunteer work.

INTELLECTUAL

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I know about available campus resources to help me study.
I feel fulfilled in my academic program.
I seek personal growth by learning new skills.
I look for ways to use my creative and critical thinking skills.
I am open to new ideas.
I learn about different topics that interest me from books, magazines, newspapers and the internet.
I know how to access academic resources when necessary.
I am comfortable reaching out to my professor/TA for help or attending office hours.
I am eager to learn.
I stay informed about social, political and other current issues.

ENVIRONMENTAL

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I spend time outdoors enjoying nature.
I reduce, reuse and recycle products.
I try to lessen my environmental impact.
I walk, bike, use public transportation or carpool when possible.
I am concerned about impacts on my local, national and world climate.
I have a space to call my own.
I feel comfortable in the space I occupy.
I feel content in my environments (class, home, work, etc.).
I shop locally.
I participate in campus events that help my community (food drives, fundraisers, etc.).

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