Sample Well-being As#5DDC9B

1 Adapted from wellcoaches Well-being assessment 2008 Page 1 of 112/3/2010 Sample Well-being AssessmentThis assessment addresses the following eight categories, as well as theimportance, readiness, and confidence in each category: Energy Stress Management Life Balance Weight Exercise Nutrition Health IssuesEnergyOften / Sometimes / Rarely / Never: In a typical work-day, my energy is high, I amvigorous, and I am able to perform at my / Sometimes / Rarely / Never: When not working, my energy is high, I amvigorous, and I am able to perform at my BOOSTERS I experience the following energy boosters in my life:Y / NHealthy sleepY / NRegular exerciseY / NHealthy eating habitsY / NStress management, relaxation, or fun activitiesY / NMaintaining healthy weightY / NMaintaining good physical healthY / NHealthy mindsetY / NHealthy work relationshipsY / NHealthy family and personal relationshipsY / NHealthy financesY / NJob satisfactionY / NOther describe _____ENERGY DRAINS I experience the following energy drains in my life.

2 Y / NPoor or insufficient sleepY / NToo little exerciseY / NUnhealthy eating habitsY / NStressY / NWeight management issuesY / NPhysical health issuesY / NPessimism or emotional issuesY / NWork relationship issuesY / NFamily or relationship issuesAdapted from wellcoaches Well-being assessment 2008 Page 2 of 112/3/2010Y / NFinancial issuesY / NJob IssuesY / NOther describe _____Readiness for Change:On a scale of 1 to 10, how ready are you to make changes or improvements in yourenergy level at this time?0 1 2 3 4 5 6 7 8 9 10_____Not readyVery readyOn a scale of 1 to 10, how important is it that you make changes or improvements inyour energy level at this time?

3 0 1 2 3 4 5 6 7 8 9 10_____Not important Very importantOn a scale of 1 to 10, how confident are you that you can make changes orimprovements in your energy level at this time?0 1 2 3 4 5 6 7 8 9 10_____Not confidentVery confidentSLEEP AND STRESSSLEEPO ften / Sometimes / Rarely / Never: I get 7-8 hours of sleep at / Sometimes / Rarely / Never: Minor problems throw me for a / Sometimes / Rarely / Never: I find it difficult to get along with people I used / Sometimes / Rarely / Never: Nothing seems to give me pleasure from wellcoaches Well-being assessment 2008 Page 3 of 112/3/2010 Often / Sometimes / Rarely / Never: I am unable to stop thinking about my / Sometimes / Rarely / Never: I feel frustrated, impatient, or angry much of / Sometimes / Rarely / Never.

4 I experience feelings of tension and / No I am coping well with my current stress / No I have suffered a personal loss or misfortune in the past year. (For example: ajob loss, disability, divorce, separation, or the death of someone close to you). If morethan one loss or misfortune, indicate number: _____Yes / No I have friends and/or family with whom I can share problems and get help / Sometimes / Rarely / Never: I feel calm and / Sometimes / Rarely / Never: I have a lot of / Sometimes / Rarely / Never: I am a happy / Sometimes / Rarely / Never: I take the time to relax and have fun / Sometimes / Rarely / Never: I feel downhearted or / Sometimes / Rarely / Never: I feel worthless, inadequate, or for Change:On a scale of 1 to 10, how ready are you to make changes or improvements in yourstress levels at this time?

5 0 1 2 3 4 5 6 7 8 9 10_____Not readyVery readyOn a scale of 1 to 10, how important is it that you make changes or improvements inyour stress levels at this time?0 1 2 3 4 5 6 7 8 9 10_____Not important Very importantAdapted from wellcoaches Well-being assessment 2008 Page 4 of 112/3/2010On a scale of 1 to 10, how confident are you that you can make changes orimprovements in your stress levelsl at this time?0 1 2 3 4 5 6 7 8 9 10_____Not confidentVery confidentLIFE BALANCEO ften / Sometimes/ Rarely / Never: I maintain a comfortable balance between Work,Family, Friends and area that I would most like to have more time for is:___ Work___ Family___ Friends___ SelfReadiness for Change:Readiness for Change:On a scale of 1 to 10, how ready are you to make changes or improvements in your lifebalancel at this time?

6 0 1 2 3 4 5 6 7 8 9 10_____Not readyVery readyOn a scale of 1 to 10, how important is it that you make changes or improvements inyour life balance at this time?0 1 2 3 4 5 6 7 8 9 10_____Not important Very importantOn a scale of 1 to 10, how confident are you that you can make changes orimprovements in your life balance at this time?0 1 2 3 4 5 6 7 8 9 10_____Not confidentVery confidentAdapted from wellcoaches Well-being assessment 2008 Page 5 of 112/3/2010 WEIGHTWEIGHT in kg (without shoes):____ Current____ 1 year ago____ 2 years ago____ 5 years ago____ 10 years agoWAIST TO HIP RATIOYour body shape is an indicator of potential risks to your health.

7 People with moreweight around their waist are at greater risk of heart disease and diabetes than thosewith more weight around their waist circumference by hip circumference to determine your waist-to-hip should ideally be below and men below have utilized the following weight-management program(s) in the last 10 years:(Describe)Readiness for Change:On a scale of 1 to 10, how ready are you to make changes or improvements in yourweight at this time?0 1 2 3 4 5 6 7 8 9 10_____Not readyVery readyOn a scale of 1 to 10, how important is it that you make changes or improvements inyour weight at this time?0 1 2 3 4 5 6 7 8 9 10_____Not important Very importantOn a scale of 1 to 10, how confident are you that you can make changes orimprovements in your weight at this time?

8 0 1 2 3 4 5 6 7 8 9 10_____Not confidentVery confidentAdapted from wellcoaches Well-being assessment 2008 Page 6 of 112/3/2010 EXERCISEI engage (how many) days per week in each of the following (indicate number ofdays):____ Aerobic exercise At least 20 minutes of vigorous intensity activity (fitnesswalking, cycling, jogging, swimming, aerobic dance, active sports) (3 or moredays desirable) OR at least 30 minutes of moderate intensity activity (5 ormore days desirable).____Strength exercises At least 10 minutes of strength-building exercises (suchas sit-ups, push-ups, or use strength-training equipment) (2-3 days desirable)____Flexibility or stretching exercise At least 5 minutes to improve flexibility ofyour back, neck, shoulders, and legs (3 days desirable)I currently have the following limitations on physical activity, if any ( , injuries,illness, medical conditions):_____I previously had the following limitations on physical activity, if any, over the last 5years:_____Readiness for Change:On a scale of 1 to 10, how ready are you to make changes or improvements in yourlevel of exercise at this time?

9 0 1 2 3 4 5 6 7 8 9 10_____Not readyVery readyOn a scale of 1 to 10, how important is it that you make changes or improvements inyour level of exercise at this time?0 1 2 3 4 5 6 7 8 9 10_____Not important Very importantOn a scale of 1 to 10, how confident are you that you can make changes orimprovements in your level of exercise at this time?0 1 2 3 4 5 6 7 8 9 10_____Not confidentVery confidentAdapted from wellcoaches Well-being assessment 2008 Page 7 of 112/3/2010 NUTRITIONO ften / Sometimes/ Rarely / Never: I eat a full breakfast each / Sometimes / Rarely / Never: I eat junk snack foods between meals ( , pastries, candy, ice cream, cookies).

10 Often / Sometimes / Rarely / Never: I eat high fat food (such as hamburgers, hotdogs, bologna, steaks, sour cream, cheese, whole milk, eggs, butter, cake, pastry, icecream, chocolate, fried foods, and many fast foods)Often / Sometimes / Rarely / Never: I eat low fat food (such as lean meats, skinlesspoultry, fish, skim milk, low fat dairy products, fruit desserts, vegetables, pasta,legumes (peas and beans).Often / Sometimes / Rarely / Never: I eat refined grain (such as white bread, rolls,regular pancakes and waffles, white rice, typical breakfast cereals, typical bakedgoods)Often / Sometimes / Rarely / Never: I eat whole grain (such as whole grain breads,brown rice, oatmeal, whole grain or high fiber cereals)Often / Sometimes / Rarely / Never: I eat 5 servings of fruits and vegetables / Sometimes / Rarely / Never: I drink eight 8 glasses of water daily.)