Questionnaire

Well-Being Questionnaire


Different aspects of life can undermine health or support and enhance it. Certain physical factors or psychological strains increase susceptibility to illness.

You can increase your resilience by identifying these traits and making necessary changes in your life. These may be in the realm of BODY, such as diet or exercise, or MIND, for example finding ways to handle stress or difficult emotions. This questionnaire is designed to enable you to find out more about the different aspects of well-being. Once you complete the questionnaire, the results page provides a statistical assessment of your overall health.

You might consider printing out your responses / results for your personal records. You might also share your results with one of our Holistic Health Navigators at (888) 707-5716 to help you find the practitioners and services that would most benefit you.
How To Fill In This Questionnaire

Go through the entire questionnaire, checking the boxes that apply to you the most. Once you have checked all the questions, click on the COMPLETE QUESTIONNAIRE button at the bottom. Then read your score to evaluate the individual aspects of your well-being. The entire process should take no more than 10 minutes.

This information is CONFIDENTIAL and is not retained by Eclectic Health or this website. Disclaimer: Eclectic Health offers this tool for educational purposes only, and is not intended to diagnose disease. This can only be done by a licensed medical health professional, and Eclectic Health does not recommend relying on the results of this questionnaire in lieu of seeing a qualified health provider.

Questions Results tab

Body

Physical Well-Being

    A = Usually     B = Sometimes     C = Never    
   A  B  C General Guidance
Physical fitness helps all the body systems function at their best and is important for the prevention of major diseases. It also boosts energy, helps reduce stress, and benefits emotional well-being. Obesity results from lack of exercise as well as over-eating, and places you at risk of developing diabetes, stroke, arthritis, and other diseases.
YOUR SCORE:
-Plenty of As show you are doing your best.
-If you have mostly Bs, find more ways to build exercise into your life.
-A high C score indicates that you seldom feel energetic. Before you start an exercise program get a medical checkup.
1 Do you feel well and energetic?
2 Are you physically fit enough to do the things you want to?
3 Are you free of unexplained physical symptoms?
4 Do you get all the sleep you need?
5 Do you exercise for at least 20-30 minutes three times a week?
6 Do you give yourself time to warm up and cool down before and after exercising?
7 Are you comfortable about your weight, shape, and physical condition?
8 Given a choice do you walk or use the stairs?
 

Risk-Taking

    A = Never     B = Sometimes     C = Frequently    
   A  B  C General Guidance
Taking unnecessary risks can endanger not just your life but those of others and it increases stress and emotional problems.
YOUR SCORE:
-A majority of A scores indicates a well-adjusted approach to life.
-If you scored mostly Bs, think about re-evaluating your lifestyle in those areas.
-Mostly Cs could mean you are unaware of potential dangers, emotionally disturbed (if so, see a doctor), or have a risk taking personality. If you answered C to questions 1-3, you may have a problem with substance addiction.
1 Do you smoke?
2 Do you use potentially dangerous recreational drugs?
3 Do you have more than three alcoholic drinks a day if a man, or two if a woman?
4 Do you take risks when driving (such as drinking alcohol, speeding, not wearing a seatbelt)?
5 Do you smoke in bed?
6 Do you carry a weapon?
7 Do you take part in dangerous sports?
8 Are you careless when working with toxic or flammable substances?
 

Nutrition

    A = Usually     B = Sometimes     C = Never    
   A  B  C General Guidance
What you eat and drink provides energy for cell growth, maintenance, and repair, and for physical and mental activity. A diet low in fats and high in fiber, fruits, and vegetables can protect against disease. Junk and processed foods are low in fiber and high in fats, added sugars, and chemical additives. Fad diets may take weight off, but are difficult to maintain and pounds lost are quickly regained.
YOUR SCORE:
-If you scored As, you are doing all you can through diet to insure well-being.
-If you scored mostly Bs, you should pay more attentionto what you eat and drink.
-If your scores are mostly Cs, your diet is possibly unhealthy and you may need to learn more about nutrition.
1 Do you eat a well-balanced, low-fat diet with high-fiber foods and plenty of fresh fruits and vegetables?
2 Do you keep your daily fat intake below 30% of calorie intake?
3 Do you keep your salt and sugar intake down?
4 Do you eat poultry and fish rather than red meat?
5 Do you rarely skip meals?
6 Do you resist eating when not hungry?
7 Do you avoid junk food and processed food?
8 Do you refrain from following fad diets?
9 Do you minimize your caffeine intake (coffee, tea, cola)?
 

Family Health

    A = No     B = Not Sure     C = Yes    
   A  B  C General Guidance
Inheritance predisposes you to some diseases, and certain conditions are passed on in the genes. Even if close relatives lived to an old age, remember that genetic disadvantages can be undone by an unhealthy lifestyle.
YOUR SCORE:
-If you scored As, you may be less at risk of inherited disease, but be aware of Red Light Symptoms and ensure that you have regular checkups.
-If you scored any Bs, talk to your doctor to arrange appropriate checkups, and to be advised of symptoms to watch out for.

Do you or a close relative (parent, sibling, offspring) who has had any of the following:
1 Treatment for high blood pressure?
2 A heart attack before the age of 40?
3 Very high cholesterol?
4 Diabetes?
5 Gout?
6 Glaucoma?
7 Breast cancer?
8 Bowel cancer?
 

Body Maintenance

    A = Yes     B = Usually     C = No    
   A  B  C General Guidance
Regular health checkups are important, particularly as you get older, to identify potential problems while a cure is still possible. While this is especially true if any close relatives have been treated for inherited diseases, environment and lifestyle contribute to many serious illnesses and can exacerbate any genetic predispositions.
YOUR SCORE:
-If you scored high in As, you are monitoring your health well.
-If you scored mainly Bs, it would be beneficial to learn more about risk factors and how to examine yourself for symptoms. You can also discuss health screenings with your doctor.
1 Do you floss your teeth daily?
2 Do you have an annual dental checkup?
3 Do you avoid over-exposure to the sun and use sunscreens when appropriate?
4 If you're ill or injured do you know what to do?
5 Women: Do you have a cervical smear at least every three years?
6 Do you check your breasts for lumps and changes every month?
7 Men: Do you check your testicles for lumps and changes at least every three months?
8 Over 40: Do you get a glaucoma test at least every four years?
9 Do you get your blood pressure checked annually?
10 Over 50: Have you discussed an occult blood stool test with your doctor?
11 Do you get a regular mammogram?
 

Work & Environment

    A = Usually     B = Sometimes     C = Never    
   A  B  C General Guidance
Feeling stimulated and fulfilled in your daily work is an important part of emotional well-being. As well as the nature of the activity itself, the conditions in which you operate are important for both physical and mental health. Although global or national environmental factors may be beyond your control, there is often a lot you can do to minimize risks in the home or workplace.
YOUR SCORE:
-If you scored high in As, you should feel on top of your work and find it enjoyable and satisfying.
-A high B score indicates that you would be well advised to examine your job and workplace to find areas for improvement.
-If you scored high in Cs and are unable to control your working conditions, perhaps you should consider the possibility of changing your job because it could be affecting your health. More information on stress and emotions may be helpful.
1 Are you well enough to work every day?
2 Do you feel secure and satisfied in what you do?
3 Do you feel valued and recognized?
4 Do you feel you have the resources you need?
5 Do you get along well with the people you deal with?
6 Do you feel you are learning and developing?
7 Do you look forward to your work day?
8 Do you feel in control of your workload?
9 Do you sit, stand, or move at work in ways that minimize strain on your back, joints, muscles, and eyes?
10 Do you take enough breaks during the day to keep your mind alert and reduce body tension?
11 Are you happy with your commute between home and work?
12 Do you feel that those closest to you at home are supportive of your work?
 

Mind

Life Events

    A = No     B = Sometimes     C = Frequently    
   A  B  C General Guidance
Remember that the degree to which pressure affects you depends on how much you feel in control and how effective your coping strategies are - whether you exercise, follow a healthy diet, and allow time for relaxation.
YOUR SCORE:
-A high A score indicates that you are fortunate to be free of major life stressors. You might consider whether your present strategies for dealing with stress could sustain you through unexpected challenges.
-If you have a majority of Bs, you may be more affected by life events than you realized and should be alert to any possible symptoms of stress.
-A high C score shows you need to use stress management techniques and pay attention to other aspects of well-being, such as nutrition, fitness, and emotional support. The following may be useful: relaxation and breathing, psychotherapy and counseling, Autogenic Training, and visualization.
1 In the last year has your life been affected by: The death of an important friend or relative?
2 Changes in close relationships (including marriage and the birth of a new baby)?
3 Moving to a new home?
4 A change of job?
5 A lay-off or retirement?
6 Major financial changes?
7 Legal problems?
8 Serious health problems (yours or those of someone close)?
9 Marital or family problems?
10 Problems with friends or neighbors?
11 Ongoing daily hassles that wear you out?
12 Do you think these events have affected you? A = hardly at all, B = moderately, C = severely
 

Values & Creativity

    A = Yes     B = Sometimes     C = Never    
   A  B  C General Guidance
A contradiction between our beliefs and our way of life creates uneasiness and dissatisfaction that can affect our emotional and ultimately physical well-being. Similarly, everyone has the capacity to be creative, whether growing flowers, cooking supper, or writing music, and the inability to fulfill our creative urges causes frustration and low self-esteem. If you feel comfortable with yourself and where you are going in life, you are less likely to be threatened by unexpected challenges and will have a flexible attitude that enables you to adapt to circumstances.
YOUR SCORE:
-If you scored high in As, you should feel a sense of commitment, coherence, and control that will enhance your ability to cope with stress.
-High B and C scores may indicate a sense of self-doubt and unhappiness and a low resistance to stress and even infection. Make a list of things you value and enjoy and examine how they fit in with the way you are living. Also look at areas of conflict, and what changes you could make.
1 Do you stay aware of political and social issues?
2 Is your work consistent with your values?
3 Are your leisure activities consistent with your values?
4 Are you able to accept people with different values and lifestyles?
5 Does your spiritual life sustain you?
6 Do you feel your life has some sense of purpose?
7 Do you feel you have a place in the scheme of things?
8 Do you feel there is enough creativity and stimulation in your life?
9 Do you welcome new possibilities?
10 Do you feel you can handle uncertainties?
11 Do you feel you can handle boredom or lack of stimulation?
 

Coping with Stress

    A = Never     B = Sometimes     C = Usually    
   A  B  C General Guidance
How you react to pressure may be influenced by your personality. Some people behave in a "hot" or hostile way, funing and blaming others, making themselves prone to coronary heart disease. "Cold" reactors may use up energy in trying to ignore the problem or in blaming themselves, and thus deplete their immune system and become vulnerable to infection. Other indications that you are not coping include compulsive or obsessive behavior, emotional problems such as insomnia, or physical conditions such as indigestion.
YOUR SCORE:
-If you scored a majority of As, you are one of those hardy characters who respond well to challenge.
-A majority of B answers indicates that you may deal well in some situations but not others, and would be well advised to learn some coping strategies.
-If you scored high in Cs, you have a coping style that is particularly vulnerable to stress. The good news is that you can learn to cope but you need to monitor yourself and make a real effort to practice stress management techniques.
1 Do you compulsively work, eat, smoke, or drink?
2 Do you feel that your life is really out of control?
3 Do you experience physical symptoms when stressed (for example, pain, palpitations, exhaustion, breathlessness, indigestion)?
4 When you are under pressure, is your mental or emotional life affected, for example, by lost interest in life, fear of disease, sleep disturbance, poor concentration, indecisiveness?
5 Do people who know you think of you as being "stressed"?
6 So you find it difficult to relax and enjoy moments of pleasure?
7 Is it hard to maintain good relationships with others, even (or especially) those closest to you?
8 When you are under pressure do you behave in a "hot" way... Do you blame other people or get angry?
9 Do you become aggressive?
10 Do you fume inwardly?
11 ...Or in a "cold" way: Do you become withdrawn and deny that there is a problem?
12 Do you become panicky?
13 Do you blame yourself or feel guilty?
 

Emotions

    A = Usually     B = Sometimes     C = Never    
   A  B  C General Guidance
A sense of humor, the ability to express yourself and share your feelings, empathy with others, and tolerance of their opinions indicate a strong sense of self-worth and high self-esteem.
YOUR SCORE:
-Many As mean you have a clear idea of your strengths and weaknessesm are at ease with yourself, and are able to take criticism.
-If your score is mostly Bs, use your answers to pinpoint areas that you need to develop.
-If you scored highly in Cs, examine your difficulties in communication and your negative opinion of yourself: they could be jeopardizing your well-being.
1 Are you unaffected by worry or guilt?
2 Do you find it easy to laugh?
3 Do you express your feelings rather than bottle them up?
4 Can you recall childhood memories without feeling bad?
5 Can you openly share intimate thoughts and feelings?
6 Can you be sensitive to other people's feelings?
7 Are you unaffected by feeling rushed or irritable?
8 Do you avoid undermining yourself with self-criticism?
 

Relationships

    A = Usually     B = Sometimes     C = Never    
   A  B  C General Guidance
Those who have partners with whom to share problems are less likely to get sick and recover faster than those without. If you feel good about yourself it's easier to have close relationships. Sexual activity concerns satisfaction in a purely physical sense, while sexual intimacy concerns the mental aspect of an emotional involvement. Thus it is possible to score A in one and C in the other.
YOUR SCORE:
-Congratulations if you scored mostly As!
-If you scored many Bs, examine the aspects of your relationships that may need attention.
-With mostly Cs you could explore ways to improve your self-esteem, ability to relax, and communication skills.
1 Do you have someone with whom you can discuss personal worries and problems?
2 Do you listen to people without interrupting them?
3 Can you accept and deal with conflict in your relations with others?
4 Do you feel no compulsion to seek approval from others?
5 Can you express what you feel or believe without feeling anxious?
6 Are you satisfied with your current level of sexual activity?
7 Are you happy with your level of sexual intimacy?
8 Are you satisfied with your use (nonuse) of contraception and/or practice of safer sex?
 

Life Management

    A = Yes     B = Sometimes     C = Never    
   A  B  C General Guidance
Managing your life to achieve balance and control involves self-confidence, self-esteem, a sense of priorities, assertiveness, the ability to say "no," and planning ahead. It also means making time for things that maintain inner harmony and help you cope with challenge.
YOUR SCORE:
-A majority of As shows your attitude toward life is positive.
-High in Bs; use these questions to examine which areas you could manage better.
-A high C score means you may feel that life is out of control, others take advantage, and you cannot cope with everyday problems
1 Do you include some relaxation time in your daily routine?
2 Do you set yourself realistic goals?
3 Do you organize your time to do things that are important to you?
4 Do you plan ahead for events that may be potentially stressful?
5 Do you feel you can rise to realistic challenges?
6 Do you accept your and others' limitations?
7 Can you make decisions without undue anxiety?
8 Do you decide what you want or feel and say so - specifically and directly?
9 Do you allow others to share tasks and responsibilities?
10 Do you get the balance between work and recreation about right?