Health & Wellbeing Assessment Form Page 4
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5Health & Wellness Assessment Form
Name:
DOB:
General Health (continued)
My Readiness to Change - General Health
My readiness to make changes or improvements in managing my health:
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I am already maintaining health management levels consistently (6 mos.+).
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I recently started working on this.
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I am planning a change this month.
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I am planning a change to start in the next 6 months.
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I have no present interest in making a change.
Sleep and Stress
Sleep: How many hours of sleep do you get on average?
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Less than 6 hours per night
7 – 8 hours per night
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6 – 7 hours per night
8 - 9 or more hours per night
Stress: Mark any symptoms below that apply to you.
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Minor problems throw me for a loop.
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I am unable to stop thinking about my problems.
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I find it difficult to get along with people used to enjoy.
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I feel frustrated, impatient, or angry much of the time.
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Nothing seems to give me pleasure anymore.
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I feel tense or anxious much of the time.
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None of the above
Personal loss: Have you suffered a personal loss or misfortune in the past year?
Examples: a job loss, disability, divorce, separation, or the death of someone close to you
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Yes - one loss
Yes - two or more
No
serious losses
Social support: Do you have friends/family with whom you can share problems/get help if needed?
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Yes
No
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Parent category: Medical