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AUDIT YOUR WELLNESS

First Name

Last Name

Email

How old are you?

70 years old or older

60-69

50-59

40-49

30-39

20-29

Under 20 years old

None

BODY — Nourishing the Physical

1. I check in throughout the day to see how my body feels.

Regularly

Sometimes

Hardly ever

None

2. I experience tightness, tension or pain regularly in my back, hips or knees.

True

False

Neutral

None

3. I experience tightness, tension or pain regularly in my upper shoulders or neck.

True

False

Neutral

None

4. I feel strong in my body and confident lifting heavier objects.

True

False

Neutral

None

5. Which of the following is most true?

I feel stiff and inflexible

I have tightness, but it doesn’t restrict my daily activities

I move well, but have some flexibility issues

I feel flexible and at ease in my body

None

6. When I sit for long periods of time, I remember to get up for movement breaks.

Yes

No

Sometimes

None

7. On average, I exercise ___ times per week.

1-2

3-4

5+

I don’t have a regular exercise practice

None

ENERGY — Feeling Vitality

1. Most days, I feel enthusiastic, energetic and fully charged.

True

False

Neutral

None

2. I describe my daily energy level as:

I start out feeling energetic, but feel low energy toward the end of the workday

I feel sustained energy throughout the day

I feel fatigued and low-energy (a “crash”) in the middle of the day

I feel fatigued and low energy most of the day

None

3. I describe my current sleep habit as:

Excellent—I get ample amounts of sleep

Average

Not great, I often have trouble sleeping

Poor, I would describe myself as sleep-deprived

None

4. During my daily activities:

I am not aware of my breathing

From time-to-time, I catch myself holding my breath

I am consciously aware of my breathing

I practice breathing exercises to enhance my energy

None

5. I would best describe my normal lunch habit as:

I eat without much distraction: consciously and in a good frame of mind

Most of the time I eat consciously, but there are days where I’m rushed or busy

I often eat at my desk or while working

I often skip lunch

None

6. I often experience digestive issues.

True

False

Neutral

None

7. When I experience stress:

I feel angry or irritated

I feel bouts of anxiety and depression

I avoid my stressors by procrastinating

On the whole I cope with stress fairly well, but every now and then I find it difficult

I seek out positive stress relief, like deep breathing, taking walks or journaling

None

MIND — Sustaining Attention

1. In my day-to-day life:

I feel restless or distracted most of the time

Sometimes I feel distracted

I feel focused most of the time

None

2. I am able to concentrate on just one thing for stretches of time – whether at work or at home.

Often: I have regular times for concentrated work or activity

Every now and then I have time to focus

I rarely have time to focus on just one thing

I multitask most of the time

None

3. When I’m given a project at work:

I prefer to go back and forth between multiple projects during the workday

I like to set aside blocks of time to work on it

I shift between being focused on one thing to moving between projects

None

4. In a high-stressed or pressured situation, I am usually able to keep calm and mentally clear.

True—I do this through effective time management, positive self-talk, regular renewal breaks or other coping mechanisms

False

It depends on the situation

None

5. I have a formal meditation practice.

Yes, I practice visualization, self-inquiry, or other formal meditation practices

Yes, I set an intention for the day

Not yet, but I’m interested in learning to meditate

No, I’m not interested in developing a meditation practice

None

6. When I have conversations with my loved ones...

I am able to bring my full attention to them and fully listen

On the whole I am able to concentrate on them, but I do get distracted

My mind wanders to other things most of the time, and I find it hard to listen

None

7. I seek out activities that will systematically build my mental capacity.

True

False

Currently false — but I am interested in starting to do this

None

BEHAVIOR — Shaping Attitudes and Character

1. When it comes to my feelings and moods:

I am always able to notice, identify and understand my feelings and moods

I am able to identify and understand my feelings and moods occasionally

I’m generally unable to understand why I’m feeling certain ways

None

2. I feel like I can manage my moods and behaviors for the benefit of my work and my relationships.

True

False

Neutral

None

3. When I feel I need to unwind, I...

Take a self-help action, such as exercising, meditating, relaxing, etc.

Occasionally I will engage in a self-help action in these moments

Self-medicate, for example, by drinking

Ignore the impulse and soldier on

Get even busier

None

4. I do a good job of separating my work time and my down time. I leave myself unscheduled time to reflect or rest.

True

False

I sometimes do this

None

5. I have practices/habits/rituals in place to help me unplug from work/family life.

Yes, I regularly am able to step away from work and recharge

I have practices in place—although I don’t always do them

No, I find it difficult to step away from work

No, I don’t have any practices to help me unplug from work

None

6. I think of my behaviors as something I can change.

True

False

I'm not sure

None

SPIRITUALITY — Finding Purpose and Fulfillment

1. I can see a clear path ahead to my goals in life and/or work.

True

False

Sometimes, but my clarity often fades

None

2. I feel I have an ability to state my truth in life.

Yes, always

Often

Sometimes

Rarely

No

None

3. I have consciously defined and prioritized my values.

Yes

No

I’m in the midst of doing this in my life

None

4. I regularly cultivate opportunities to connect with my creativity.

True

False

Not regularly, but I sometimes do this

None

5. I would best describe my morning routine as:

I have a morning routine that involves a ritual or practice for increasing energy, focus or attention

I set a daily intention or affirmation

I exercise every morning

I have a morning routine that involves self-care, but often I don’t do it

Frantic, rushed and/or hectic

None

6. I would best describe my bedtime ritual or routine as:

Falling asleep on the couch

Watching television

Scrolling through social media in bed

Reading a book or magazine in bed

Taking a shower/bath, reviewing my day, or doing a self-care ritual

I don’t have a ritual or routine

None

7. I feel a connection with a spiritual purpose or source.

True

False

I’m still figuring this out

None

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