• Personal Details
  • Assessment

Personal Details

Tell us something more about you

All Fields are Required

On the following form, please select the number which best identifies your response to each corresponding statement.

  1. Never or Almost Never
  2. Occasionally
  3. Often
  4. Very Often
  5. Always or Almost Always

Physical Activity

1. I engage in moderate physical activity outside of work for at least 20 to 30 minutes at least 5 days of the week.

2. My physical activity includes stretching, aerobic activity, and strength conditioning.

3. I use alternative modes of transportation whenever possible to and from various locations (i.e. stairs instead of elevator, biking or walking instead of driving).

4. I take the health benefits of physical activities and their lasting impact seriously.

5. I enjoy sedentary activities rather than physical activities.


6. I eat at least five servings of fruits and vegetables every day (one serving equals one half cup).

7. I eat at fast food restaurants less than three times per week.

8. I include foods that are high in fiber in my diet on a daily basis (i.e. whole grain breads and cereals, beans, etc.)

9. I maintain a healthy weight within the recommendations specified by a health care professional.

10. I avoid eating foods that are high in fat such as whole milk, fried foods, fatty meats, etc.

General Health

11. I avoid the use of tobacco products (cigarettes, smokeless tobacco, cigars, and pipes) and limit myself to 5 drinks of alcohol a week. (beer, liquor, wine)

12. I examine my breasts or testes on a monthly basis.

13. I protect my skin from sun damage by using sunscreen, wearing hats, and/or avoiding tanning booths and sunlamps.

14. I visit my dentist every six months for regular check ups.

15. I see my physician for routine check-ups, health screenings, and disease prevention.


16. I wear a seat belt when traveling in a vehicle.

17. I stay within five miles per hour of the speed limit.

18. I know where to locate and properly use a first aid kit and fire extinguisher in case of an emergency.

19. I use the recommended safety equipment for all activities that I participate in (i.e. mouth guards, life jackets, hard hats, etc.).

20. I take the proper precautions to avoid or reduce workplace accidents. (i.e. clean up spills)

Social and Environmental Wellness

21. I regularly recycle my paper, plastic, glass and aluminum.

22. I respect the integrity and property of my fellow co-workers and the surrounding environment.

23. I take time to have meaningful interactions with family and friends.

24. I contribute time and/or money to at least one organization that strives to better the community where I live.

25. I regularly take interest in and interact with others.

Emotional Awareness

26. My relationships and behaviors are maintained in a manner which is healthy for me and for others.

27. I am able to develop close, personal relationships with others.

28. I have positive relationships with both men and women in my life.

29. I feel that I am a confident individual.

30. I am able to respect others for who they are, regardless of race, gender, age, attitude, and interests.

Mental Wellness

31. I express my feelings of anger and frustration in ways that are not hurtful to myself or others.

32. I set reasonable objectives for myself and strive to accomplish them.

33. I realize when I make mistakes; and I understand the consequences that they have on myself and others.

34. I feel that I have family and friends that I can confide in to assist in managing stress.

35. I take responsibility for my actions and understand the effects that they have on others.

Intellectual Wellness

36. I keep informed about social, political, and/or current events.

37. I seek opportunities to learn new things through different mediums such as television, books, newspaper, internet, etc.

38. Before making decisions, I gather facts and consider all viable options.

39. I enjoy activities such as the arts, visiting museums, or attending plays or concerts.

40. I enjoy learning new information on a daily basis.

Occupational Wellness

41. I enjoy my work.

42. I am satisfied with the balance between my work time and leisure time.

43. I am satisfied with my ability to manage and control my work load.

44. The level of stress in my work environment is manageable for me.

45. At work, my level of authority is consistent with my level of responsibility.

Values, Spirituality, and Beliefs

46. I feel that my life has a purpose.

47. I am able to discuss my values and beliefs with my family and friends in a reasonable manner.

48. My actions are guided by my own beliefs rather than the beliefs of others.

49. I spend a portion of every day in personal reflection.

50. I am tolerant of the values and beliefs of others.