Health and Wellness Self-Assessment

This form is about self-reflection. Please use this opportunity to assess your happiness scale, and to help you to identify if there are lifestyle changes that you would like to make. Determine how stressed you are day to day and discover what you can do about it.

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Section 1 - Basic Information about you

On a scale of 1 to 10, think about how you would rate your overall happiness and life satisfaction at the moment?

(1 being extremely unhappy, 10 being extremely happy)

Keep this number in your mind as you answer the remaining quesitons.

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Describe your current stress level on a daily basis?

Answer:

Very low

Low

Moderate

High

Very high

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Do you feel that you have a healthy work-life balance?

Consider the type of work schedule you have, in person, hybrid, work from home or perhaps you do not work.

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How many hours a day do you spend on electronic devices?

Include phone, tablets, computers, TV etc.

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Section 2 - Self-Reflection

In the next few slides, you will be provided with several sentences. Please indicate to what degree you agree with them on a scale of 1 (strongly disagree) to 5 (strongly agree).

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I make healthy food choices and have good nutritional habits?

What is your relationship with food and beverages? Do you follow specialized diet plans?Have you made any dietary changes?

1 Strongly disagree

2 Disagree

3 Most of the time

4 Agree

5 Strongly agree

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How often do you engage in physical activity/exercise every week?

Remember to include counting daily steps using a tracker.

1 Rarely or never

2 1-2 times a week

3 3-4 times a week

4 5 or more times a week

5 Every day

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How connected do you feel to your social support network ?

Do you feel connected to family, friends etc.

1 Very connected

2 Moderately connected

3 Somewhat connected

4 Not connected

5 I am not interested in connecting with others

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I feel that I am proactively handling my stress.

1 Very well

2 Moderately well

3 Somewhat well

4 Not well at all

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How many hours of quality sleep do you typically get each night?

How well rested are you when you get up?

1 Less than 5 hours

2 5-7 hours

3 7-8 hours

4 More than 8 hours

5 I generally do not sleep well

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Section 3 - Personal Reflection

In the following section, please reflect on any insights related to your current well-being and think about potential areas for improvement.

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Are there specific areas of your life (relationships, work, health) that you feel need improvement for better overall well-being?

Please remember that the results are not a substitute for professional advice, and if needed, seeking guidance from a healthcare or mental health professional is recommended.

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Which of the following could help you accomplish your goals related to increasing your overall life happiness? (Select all that apply)

Health and Wellness Coaching

Self help books, educational resources

Advice from a medical or mental health professional

Support from family, friends or work colleagues

Other

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On a scale of 1 to 10, think about how you would rate your overall happiness and life satisfaction at the moment? (1 being extremely unhappy, 10 being extremely happy)

1-4 very unhappy

5 sometimes happy, sometimes not

6-8 happy most of the time

9-10 extremely happy

Your responses have been recorded.

I appreciate that you took the time to complete this brief wellness assessment, and I trust that it provided valuable insights for you to reflect on your current lifestyle and well-being.

Should you have any questions related to your journey to better health and happiness, please don't hesitate to contact me.

info@torontowellnesscoach.ca

Remember, your well-being matters !

Sharon