Well-Being Survey
Answer the following questions, honestly. This is for your eyes only!
Place an “X” in the box corresponding with your answer.
Write “yes” or “no” in the 3rd column if this is a behavior you are willing to work on changing.
| Questions |
Yes |
No |
Occasionally |
I am willing to work on
changing this behavior?
Yes/No |
| 1. I stay away from smoking? |
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| 2. I stay away from drinking alcohol? |
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| 3. I avoid using illegal drugs? |
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4. I eat a variety of food each day,
including fruits and vegetables? |
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| 5. I limit the amount of fats in my diet? |
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6. I limit the amount of sugars/sweets
in my diet? |
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| 7. I avoid skipping meals? |
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8. I participate in aerobic activities for
a minimum of 30 minutes 5x/week? |
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9. I maintain good body weight, not too heavy,
not too skinny? |
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| 10. I manage stress well? |
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11. I express my feelings and do not hold
them in? |
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12. I have regular check-upds with my
family physician? |
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If the majority of your answers fall into the “Yes” category, you’re doing great! Keep up the good work! If the majority of your answers are “No,” then you might want to re-evaluate your activities and behavior. They might not be so good for you!
If your answers are split pretty evenly between “Yes” and “No,” you may need to make a few changes in your lifestyle.
To become more physically fit and healthy, there are many behaviors you can change because they are in your control. Choose only a couple of behaviors to begin with, and as you conquer these changes, add another one or two. Remember, no one can change everything at one time and be successful!
http://pbskids.org/itsmylife
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