Wellness Evaluation
Physical Wellness
Rarely
Sometimes
Most of the time
Always
I exercise for less than 30
minutes/day on 3 or more days
per week.
1
2
3
4
I am physically active most days of
the week.
1
2
3
4
I maintain a healthy body weight
1
2
3
4
I always use my seatbelt when
driving or riding in a car
1
2
3
4
I never drink and drive and do not
ride with anyone who has been
drinking
1
2
3
4
I obey traffic rules and speed
limits
1
2
3
4
I consistently get 7-9 hours of
sleep
1
2
3
4
I am able to sleep peacefully
through the night
1
2
3
4
I eat a variety of foods including
fruits and veggies
1
2
3
4
I avoid skipping meals
1
2
3
4
I rarely eat processed foods
and/or sweets
1
2
3
4
I consume less than two alcoholic
beverages a day
1
2
3
4
I never get intoxicated
1
2
3
4
I do not binge drink
1
2
3
4
I never smoke or use smokeless
tobacco
1
2
3
4
I do not use illegal drugs
1
2
3
4
I use prescription medications only
for their intended purpose
1
2
3
4
I get annual medical examinations
1
2
3
4
I am not sexually active or I always
practice safe sex (ex- use condoms
or being involved in a
monogamous relationship)
1
2
3
4
Total
Points________47_______
Social Wellness
Rarely
Sometimes
Most of the time
Always
I have a happy and satisfying relationship
with my spouse/ boyfriend- girlfriend
1
2
3
4
I have good relationships with my close
friends
1
2
3
4
I get a great deal of love and support from
my family
1
2
3
4
I work to have good communication skills
1
2
3
4
I am able to express my feelings to people
close to me
1
2
3
4
Total
Points_______19________
Emotional Wellness
Rarely
Sometimes
Most of the time
Always
I find it easy to relax
1
2
3
4
I regularly participate in activities
and hobbies I enjoy
1
2
3
4
I am able to cope with daily
1
2
3
4
emotional stress
stressful life event in the last
year
I do not suffer from depressive or
anxiety disorders
1
2
3
4
I have an eating disorder
I am able to accept responsibility
for my own feelings and actions
1
2
3
4
I keep informed about current events
I seek opportunities to learn new things
that may be different than mine
