Wellness Status Questionnaire Wellness Status and Health Behavior Questionnaire There are many known aspects of life that greatly influence your well-being and your health. These factors will influence how fast you can heal. This questionnaire seeks to determine how well you feel these various aspects of your life are currently going, and what lifestyle choices or behaviors you currently undertake that would improve your health and well-being. Your Name* SECTION A – Your current wellness statusInstructions: Please answer ALL the scales, based on how you have felt on average; in other words, the majority of the time in the past week. For each 0-10 scale the end-descriptors of 0 and 10 are described under each question. If you feel like you experience equally both extremes then you can tick the box labeled 5, or you may feel you are closer to one extreme than the other.1.) Over the past week, how well have you slept? Terrible means you have had too little and/or very broken sleep every night of the past week. Fantastic in this case means you have had a good, continuous 8 or 9 hours of sleep each night last week.SelectTERRIBLE234Ok6789FANTASTIC!2.) Over the past week, how well-rested have you felt in the mornings? Not at all rested in this case means you have woken up feeling exhausted and non-rested every morning of the past week, while completely rested in this caseSelectTERRIBLE234Ok6789FANTASTIC!3.) Over the past week, how good do you feel your social life is? Terrible means you have had no time to see any friends and/or that you do not feel supported by your social network, and Fantastic in this case means you have been able to catch up with friends and you do feel supported by your social network.SelectTERRIBLE234Ok6789FANTASTIC!3.) Over the past week, how good do you feel your social life is? Terrible means you have had no time to see any friends and/or that you do not feel supported by your social network, and Fantastic in this case means you have been able to catch up with friends and you do feel supported by your social network.SelectTERRIBLE234Ok6789FANTASTIC!4.) Over the past week, how well have you felt mentally? Terrible in this case indicates you have had lots of depressive(sad, tearful, negative, unhappy) and/or anxious feelings (tense, worried, fearful, nervous, uptight, irritable, difficulty concentrating/relaxing), while Fantastic means you have experienced lots of positive feelings (such as happiness, excitement, joy, hope, and inspiration) and you feel you coped well with any depressive and/or anxious feelings.SelectTERRIBLE234Ok6789FANTASTIC!5.) Over the past week, how well has your stomach and gut felt? Terrible in this case indicates you have had a lot of functional digestive issues like frequent heartburn, burping, gas, constipation, diarrhea, and/or abdominal pain, while Fantastic in this case means you have no digestive complaints and have two or three easy bowel movements every day.SelectTERRIBLE234Ok6789FANTASTIC!6.) Over the past week, how well have you been breathing? Terrible in this case indicates you feel a tension around your rib cage, struggle to take deep easy breaths, sigh a lot, yawn a lot, etc. While terrific in this case means you feel you can always take a full deep breath with no tension or breathing difficulties.SelectTERRIBLE234Ok6789FANTASTIC!7.) Over the past week, how well do you feel your relationship has been with your significant other (e.g. girlfriend/boyfriend/wife/husband/partner)? Terrible in this case indicates you do not feel supported, loved or cared for by your partner and that you have either been completely ignored or that you have had ongoing disagreements, arguments and/or fights most of the time. While terrific in this case means you feel you have been able to have constructive conversations, overcoming difficulties, and that you feel close to your partner, loved and supported most days last week.SelectTERRIBLE234Ok6789FANTASTIC!8.) Over the past week, how well do you feel your relationships with your close family members have been (e.g. your children, parents and siblings)? Terrible in this case indicates you do not feel your close family relationships are loving and supportive, and that you have either been completely ignored or that you have had ongoing disagreements, arguments and/or fights most of the time. While terrific in this case means you feel you have loving, supportive relationships with all of your close family members and that if you have had interactions with them you have had constructive conversations, overcome difficulties, and that you feel close to all of your family members most of the time.SelectTERRIBLE234Ok6789FANTASTIC!9.) Over the past week, how well has your diet been? Terrible in this case indicates you have eaten poorly, mostly junk food (highly processed foods full of bad fats and artificial colors and flavorings). While terrific in this case means you have had regular healthy meals containing lots of fresh fruits, fresh vegetables, good quality protein, healthy fats and complex carbohydrates.SelectTERRIBLE234Ok6789FANTASTIC!10.) Over the past week, how well do you feel your work life has been? Terrible in this case indicates your work life and/or work relationships brings you a lot of grief and stress. This could be because you have no work, or because of pressures you feel from work, and/or due to difficult relationships with work colleagues. While terrific in this case means you feel you have a great work life, you feel valued, and you feel your contribution mattersSelectTERRIBLE234Ok6789FANTASTIC!Section B - Your current health promoting behaviorsInstructions: Please answer ALL the scales, based on how often you participated in the following wellness behaviors during the last week. For each question, options are from 'Never' to "Every Single Day" are offered, choose your answer accordingly.1.) Over the past week, how many days have you exercised (e.g. gone for a walk or run and/or done any strength training, such as lifting weights or doing squats and/or sit-ups)?SelectNeverOnce a weekTwice a WeekThree times a WeekFour times a WeekFive times a WeekSix times a weekEvery Day2.) Over the past week, how often have you done mindfulness meditation?SelectNeverOnce a weekTwice a WeekThree times a WeekFour times a WeekFive times a WeekSix times a weekEvery Day3.) Over the past week, how often have you practiced conscious breathing exercises?SelectNeverOnce a weekTwice a WeekThree times a WeekFour times a WeekFive times a WeekSix times a weekEvery Day4.) Over the past week, how often have you practiced gratitude?SelectNeverOnce a weekTwice a WeekThree times a WeekFour times a WeekFive times a WeekSix times a weekEvery Day5.) Over the past week, how often have you had a positive attitude or been thinking positively about your situation and/or about what has happened this week?SelectNeverOnce a weekTwice a WeekThree times a WeekFour times a WeekFive times a WeekSix times a weekEvery Day6.) Over the past week, how often have you taken a ‘sensory siesta’ (a break from sensory input by lying down with a blanket over you, eye covers, noise-suppression headphones or in a quiet place and thought about nothing for 20 minutes)?SelectNeverOnce a weekTwice a WeekThree times a WeekFour times a WeekFive times a WeekSix times a weekEvery Day7.) Over the past week, how often have Over the past week, how often have you carefully considered eating healthy, natural foods (fresh fruit, fresh vegetables, nuts and seeds, good quality protein, complex carbohydrates and healthy fats) and been present mentally while you ate?taken a ‘sensory siesta’ (a break from sensory input by lying down with a blanket over you, eye covers, noise-suppression headphones or in a quiet place and thought about nothing for 20 minutes)?SelectNeverOnce a weekTwice a WeekThree times a WeekFour times a WeekFive times a WeekSix times a weekEvery Day8.) Over the past week, how often have you taken care of your gut and microbiome by eating fresh healthy foods and/or taking prebiotics and/or probiotics?SelectNeverOnce a weekTwice a WeekThree times a WeekFour times a WeekFive times a WeekSix times a weekEvery Day9.) Over the past week, how often have you taken any good quality health supplements?SelectNeverOnce a weekTwice a WeekThree times a WeekFour times a WeekFive times a WeekSix times a weekEvery Day10.) Over the past week, how often have you taken any good quality health supplements?SelectNeverOnce a weekTwice a WeekThree times a WeekFour times a WeekFive times a WeekSix times a weekEvery Day11.) Over the past week, how often have you had good healthy intimate connections (such as hugs, kisses, cuddles and/or sex)?SelectNeverOnce a weekTwice a WeekThree times a WeekFour times a WeekFive times a WeekSix times a weekEvery DayEmailThis field is for validation purposes and should be left unchanged.
