How is Your Well-Being & Self-Care?

Emotional Self-Care

1. Are you able to identify and label your emotions as you experience them?

a. Yes, I am able to label and identify my emotions.

b. Most of the time I am able to label and identify my emotions.

c. Occasionally I can label and identify my emotions, but it is a challenge to do so.

d. Rarely am I able to label and identify my emotions.

e. I almost never am able to label and identify my emotions.

2. Which of the following statements is most true to you?

a. I always let my emotions take over my life and it has caused problems in my life.

b. I often let my emotions take over my life; I am very reactive and this causes stress in my life.

c. Sometimes I let my emotions take over my life, it depends on the situation and my level of stress.

d. I rarely let my emotions take over my life, I can manage my feelings pretty well.

e. I never let my emotions take over my life, I can manage my feelings well.

3. When you experience a negative emotion (eg. irritability, anger, sadness) how do you cope with it?

a. I always cope with negative emotions in healthy ways.

b. I often cope with negative emotions in healthy ways.

c. I sometimes cope with my negative emotions through healthy and unhealthy coping skills.

d. I rarely cope with negative emotions, I use unhealthy coping skills and struggle to use healthy coping skills.

e. I never cope with negative emotions and have experienced significant stress in my life because of it.

5. How would you answer this statement: I feel hopeful and optimistic about the future.

a. I completely agree with this statement.

b. I mostly agree with this statement.

c. Some of the time I would agree with this statement.

d. Rarely would I agree with this statement.

e. Never would I agree with this statement.

6. Which statement would you say most accurately describes you?

a. I feel calm and happy most days.

b. I have a lot of stress but feel happy often.

c. I am stressed and tired often.

d. I often feel bored and don't have much fun.

e. I feel unhappy and stressed all of the time.

Physical Self-Care

1. How often do you exercise?

a. Every day, exercise is part of my routine.

b. At least 3-5 times a week.

c. Two times a week.

d. Rarely do I exercise.

e. I never exercise.

2. Do you get at least 7 hours of sleep each night?

a. Every night I get at least 7 hours of sleep.

b. Most nights I get at least 7 hours of sleep.

c. Sometimes I get 7 hours of sleep, depends on the night.

d. Rarely do I get 7 hours of sleep.

e. I never get 7 hours of sleep.

3. How would you describe your nutrition and diet?

a. Very healthy and nutritionally-balanced.

b. Mostly healthy and nutritionally-balanced.

c. Sometimes I eat healthy and nutritionally-balanced foods, but it's a struggle.

d. Rarely do I eat healthy and nutritionally-balanced.

e. I never eat healthy or nutritionally-balanced food.

4. Do you routinely shower/bathe, wear clean clothes, and groom yourself daily?

a. Every day.

b. Almost every day.

c. Sometimes.

d. Rarely.

e. Never.

5. Do you go to annual medical appointments (annual check-ups, dental cleanings, etc)?

a. Yes, I never miss them.

b. Most of the time.

c. Sometimes, I have to admit I often forget.

d. Rarely.

e. Never.

6. How would you describe your libido (sexual desire or interest in engaging in sexual activity)?

a. No issues with my libido, I wouldn't change a thing.

b. Minor issues with my libido, I wish I had more sexual desire.

c. Moderate issues with my libido, I think it could be better.

d. Serious issues with my libido, I barely have any sexual desire.

e. I have no libido at all.

7. How much caffeine do you consume each day?

a. None.

b. One to two servings.

c. Three to five servings.

d. Six to eight servings.

e. Over nine servings.

8. On average, how many alcoholic drinks do you consume weekly? (12 oz. beer or 5 oz. wine or 2 oz. liquor)?

a. None.

b. One to two servings

c. Three to four servings.

d. Five to six servings.

e. More than six.

9. Has your alcohol use caused problems or issues in your personal life, relationships, at work or resulted in legal issues (eg. driving intoxicated, assault, or disorderly conduct charges)?

a. Yes

b. No.

10. Do you skip eating meals?

a. Daily

b. Often

c. Occasionally

d. Almost never

e. Never

11. Do you use food as a way to cope with your feelings or manage stress?

a. Every day

b. Several times a week

c. On occasions, when I'm really stressed.

d. Rarely.

e. Never.

12. Do you nap or sleep as a way to avoid dealing with the stress or challenges in your life?

a. All the time.

b. A good amount

c. Occasionally

d. Rarely

e. Never

13. Do you use alcohol as a way to unwind and relax?

a. Every day I need a drink to cope with stress and relax.

b. Several times a week I use alcohol to cope with stress and relax.

c. Only on the weekends do I use alcohol to cope with stress and relax.

d. Rarely do I use alcohol to cope with stress and relax.

e. I never use alcohol to cope with stress and relax.

Mental/Cognitive Self-Care

1. Would you describe your days as interesting and mentally stimulating?

a. Yes, my days are interesting and mentally stimulating.

b. Almost every day is interesting and mentally stimulating.

c. Sometimes my day is interesting and mentally stimulating.

d. Seldom is my day interesting and mentally stimulating.

e. I never have an interesting and mentally stimulating day.

2.How would you describe your mind's daily mental chatter, also described as self-talk?

a. Upbeat and positive self-talk

b. Mostly upbeat and positive but occasionally negative

c. A combination of positive and negative self-talk

d. Mostly negative and critical self-talk.

e. Constant negative and critical self-talk.

3. How often do you experience flow, the experience when you are doing something you love and enjoy and lose track of or forget about time?

a. Almost every day I experience flow.

b. I frequently experience flow.

c. On occasion I experience flow.

d. I rarely experience flow.

e. I never experience flow.

4. How would you describe your memory and ability to recall information?

a. Great, no changes in my memory.

b. Pretty good, slight change but only when I'm tired or stressed.

c. Some changes, but I'm not too concerned.

d. Serious changes, I am concerned.

e. Significant changes, I'm worried.

5. How often do you feel bored?

a. Never, who has time to feel bored?

b. On occasion, I feel bored, but not often.

c. Sometimes, because some days are just so boring doing the same thing over and over.

d. Most of the time I feel bored.

e. Every day and all of the time.

6. Do you have hobbies and interests that you engage in?

a. Yes, all the time; I make sure to put it in my schedule.

b. Yes, as often as I can.

c. Sometimes, I wish I could do more, but finding time is difficult.

d. Rarely, I've lost interest in many things that I used to enjoy.

e. No, I have lost interest in everything I once enjoyed.

Social Self-Care

1.Which statement most closely describes your friendships?

a. I have a large group of friends who are emotionally supportive.

b. I have a couple of close friends who are emotionally supportive.

c. I have some friends, who at times are emotionally supportive, and other times are not.

d. I have some friends, but with limited emotional support.

e. I have no friends and don't have much emotional support.

2.Would you describe your immediate family as supportive?

a. Always

b. Mostly

c. Sometimes

d. Rarely

e. Never

3. If you needed help because of an illness or injury, would friends and family be available for help?

a. Extremely likely

b. Likely

c. Not sure

d. Unlikely

e. Extremely unlikely

4. If you wanted to go on a day trip, outing, or event, could you easily find someone to go with?

a. Definitely, it would be hard to choose who to invite

b. Easily, but I may have to make some calls

c. Not sure, it could be challenging

d. It would be difficult

e. Probably not

5. What statement most closely describes the relationship with your significant other/partner/spouse?

a. Supportive and healthy

b. Most of the time supportive

c. A combination of supportive and stressful

d. Mostly stressful

e. Physically, verbally, or emotionally abusive

f. Not applicable, I am not in a relationship

6. Do you feel a sense of belonging and importance within your social relationships?

a. Definitely

b. Almost always

c. Occasionally

d. Seldom

e. Never

Spiritual Self-Care

1. Do you spend time outside observing and enjoying nature?

a. Every day, I love being outdoors in nature.

b. As much as I can, I enjoy nature when I am able to.

c. Occasionally, I spend time outdoors.

d. Almost never, it's not that I don't want to, I just don't have the time.

e. Never, I don't like being outside.

2. Do you find meaning and purpose in your day whether at home, work, or in your community?

a. Every day

b. Several times a week

c. Occasionally

d. Rarely

e. Never

3. Do you think you make a difference in the lives of others?

a. Absolutely, I'm sure of it; I make a difference.

b. Most of the time I make a difference.

c. I don't give it much thought, but I sure hope so.

d. I don't think so, but who knows.

e. I do not believe I make a difference in the lives of others.

4. If you are part of a religious group, do you attend or participate in religious rituals and/or services? (this question is not graded)

a. I attend services every day.

b. Once a week I attend services.

c. Only a couple of times a year do I attend services.

d. I belong to a religious group but I do not attend services.

e. I am not part of a religious group.

5. Do you feel a sense of connection to others, not only those you know, but also in your community and the world in general?

a. Yes, I feel a sense of connection to others regardless If I know them.

b. Most of the time I feel a sense of connection to others, even people I don't know.

c. Sometimes, I feel connected to others regardless of if I know them or not.

d. Rarely do I feel connected to others beyond those I know.

e. I never have a sense of connection to others.

6. Do you spend time in prayer? (this question is not graded)

a. Daily

b. Several times a week

c. Occasionally

d. Rarely

e. Never

7. Do you meditate?

a. Daily

b. Several times a week

c. On occasion

d. Seldom

e. Never

8. Do you routinely express gratitude in your life?

a. Every day

b. Most of the time

c. Sometimes

d. Seldom

e. Never

9. Do you take time to reflect on what is important to you in life?

a. Every day

b. Most of the time

c. Sometimes

d. Seldom

e. Never

Is there a topic or concern you would like to learn more about?

Personal Information

This section is not scored. It is only gathered for information purposes and demographic research.

* First Name:

Last Name:

Marital Status:

Single

Married

Divorced

Widowed

In a relationship

It's complicated

Number of children:

One

Two

Three

Four

Five or more

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