Participant Wellbeing Assessment
Please complete this form to help us understand your current wellbeing across several areas.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Overall, how would you rate your current wellbeing?
*
Very Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Very Poor, 10 is Excellent
How often have you felt stressed in the past week?
*
Never
Rarely
Sometimes
Often
Always
Please rate the following aspects of your wellbeing over the past week.
*
Rows
Very Poor
Poor
Average
Good
Excellent
Sleep Quality
1
2
3
4
5
Energy Levels
6
7
8
9
10
Mood
11
12
13
14
15
Ability to Focus
16
17
18
19
20
Physical Activity
21
22
23
24
25
How supported do you feel by those around you?
*
1
2
3
4
5
How would you describe your eating habits over the past week?
*
Very unhealthy
Somewhat unhealthy
Neutral
Somewhat healthy
Very healthy
What activities help you relax or improve your wellbeing?
Exercise
Meditation or mindfulness
Spending time with friends/family
Reading
Creative hobbies (art, music, etc.)
Other
Is there anything else you would like to share about your wellbeing?
Submit Assessment
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