Name
First Name
Last Name
Email
1. I eat at least one, hot balanced meal a day.
1 - Almost Always
2 - Fairly Often
3 - About half the time
4 - Occasionally
5 - Never
2. I get seven to eight hours of sleep 4 nights/week
1 - Almost Always
2 - Fairly Often
3 - About half the time
4 - Occasionally
5 - Never
3. I give and receive affection regularly
1 - Almost Always
2 - Fairly Often
3 - About half the time
4 - Occasionally
5 - Never
4. I have at least one support within 30kms on whom I can rely
1 - Almost Always
2 - Fairly Often
3 - About half the time
4 - Occasionally
5 - Never
5. I exercise to the point of perspiration at least once per week
1 - Almost Always
2 - Fairly Often
3 - About half the time
4. Occasionally
5. Almost Always
6. I smoke less than 10 cigarettes per day (Enter "1" if you do not smoke)
1 - Almost Always
2 - Fairly Often
3 - About half the time
4 - Occasionally
5 - Never
7. I drink fewer than five alcoholic beverages per week (Enter "1" if you do not drink or drink less than 5 alcoholic beverages)
1 - Almost Always
2 - Fairly Often
3 - About half the time
4 - Occasionally
5 - Never
8. I am the appropriate weight for my age and body type
1 - Almost Always
2 - Fairly Often
3 - About half the time
4 - Occasionally
5 - Never
9. I have income adequate to meet my basic expenses
1 - Almost Always
2 - Fairly Often
3 - About half the time
4 - Occasionally
5 - Never
10. I get strength from my religious or spiritual beliefs
1 - Almost Always
2 - Fairly Often
3 - About half the time
4 - Occasionally
5 - Never
11. I attend a club or social activities
1 - Almost Always
2 - Fairly Often
3 - About half the time
4 - Occasionally
5 - Never
12. I have a network of friends and acquaintances
1 - Almost Always
2 - Fairly Often
3 - About half the time
4 - Occasionally
5 - Never
13. I have one or more close friends
1 - Almost Always
2 - Fairly Often
3 - About half the time
4 - Occasionally
5 - Never
14. I am in good health (including eyesight, hearing, and teeth)
1 - Almost Always
2 - Fairly Often
3 - About half the time
4 - Occasionally
5 - Never
15. I am able to speak openly about my feelings when angry or worried
1 - Almost Always
2 - Fairly Often
3 - About half the time
4 - Occasionally
5 - Never
16. I have regular conversations with the people I live with about domestic problems such as chores, babysitting, etc.
1 - Almost Always
2 - Fairly Often
3 - About half the time
4 - Occasionally
5 - Never
17. I do something for fun at least once a week
1 - Almost Always
2 - Fairly Often
3 - About half the time
4 - Occasionally
5 - Never
18. I am able to organize my time efficiently
1 - Almost Always
2 - Fairly Often
3 - About half the time
4 - Occasionally
5 - Never
19. I drink fewer than three cups of coffee/tea/cola/chocolate a day
1 - Almost Always
2 - Fairly Often
3 - About half the time
4 - Occasionally
5 - Never
20. I take some quiet time to myself everyday
1 - Almost Always
2 - Fairly Often
3 - About half the time
4 - Occasionally
5 - Never
Total Score
