Health & Wellness Self-assessment Form
Reflect on your current health and wellness. Please answer each question honestly for your personal self-assessment.
Overall, how would you rate your current physical health?
*
1
2
3
4
5
How would you describe your typical energy levels throughout the day?
*
Very high
High
Moderate
Low
Very low
In the past week, how often have you felt stressed or overwhelmed?
*
Never
Rarely
Sometimes
Often
Always
How satisfied are you with the quality of your sleep?
*
1
2
3
4
5
How many days per week do you engage in physical activity (30+ minutes)?
*
0 days
1–2 days
3–4 days
5–6 days
7 days
How balanced do you feel your nutrition is?
*
1
2
3
4
5
Please rate your general mood over the past week.
*
Very negative
1
2
3
4
Very positive
5
1 is Very negative, 5 is Very positive
How frequently do you practice relaxation or mindfulness (e.g., meditation, deep breathing)?
*
Never
Rarely
Sometimes
Often
Daily
How would you rate your ability to manage daily responsibilities and tasks?
*
1
2
3
4
5
Please indicate your current satisfaction with the following aspects of your wellbeing:
*
Rows
Very dissatisfied
Dissatisfied
Neutral
Satisfied
Very satisfied
Physical health
1
2
3
4
5
Mental wellbeing
6
7
8
9
10
Social connections
11
12
13
14
15
Work-life balance
16
17
18
19
20
Submit Self-assessment
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