Your Deep Health Check- In Name * First Name Last Name Email * Physical Wellbeing 1. How is your energy level lately? Strongly Disagree Disagree Neutral Agree Strongly Agree 2. How pain-free are you lately? Strongly Disagree Disagree Neutral Agree Strongly Agree 3. How recovered do you feel recently? (Or, how much do you feel like working out?) Strongly Disagree Disagree Neutral Agree Strongly Agree Survey 4. How has your general mood and outlook been lately? Strongly Disagree Disagree Neutral Agree Strongly Agree 5. How well do you feel that you can express your emotions directly, maturely, and honestly? Strongly Disagree Disagree Neutral Agree Strongly Agree 6. How able are you to calm yourself down when you’re upset or anxious? Strongly Disagree Disagree Neutral Agree Strongly Agree Survey 7. How calm and focused do you feel lately? Strongly Disagree Disagree Neutral Agree Strongly Agree 8.How confident and capable do you feel lately? Strongly Disagree Disagree Neutral Agree Strongly Agree 9. What happened the last time you were presented with a big logistical challenge? Strongly Disagree Disagree Neutral Agree Strongly Agree Survey 10. How much do you identify with a bigger “why” or “purpose” for living? Strongly Disagree Disagree Neutral Agree Strongly Agree 11. How does the way you are living right now reflect your deeper values? Strongly Disagree Disagree Neutral Agree Strongly Agree 12. How often do you feel hopeful and optimistic about the world or life in general? Strongly Disagree Disagree Neutral Agree Strongly Agree Survey 13. How supported do you feel right now by the people around you? Strongly Disagree Disagree Neutral Agree Strongly Agree 14. Can be your authentic self with the people you spend the most time with? Strongly Disagree Disagree Neutral Agree Strongly Agree 15. Do the people around you encourage healthy behaviors? Strongly Disagree Disagree Neutral Agree Strongly Agree Environmental Wellbeing 16. Is your home environment relatively clean, safe, and free of toxins? Strongly Disagree Disagree Neutral Agree Strongly Agree 17. Does what’s around you actively contribute to your wellbeing and healthy behaviors? Strongly Disagree Disagree Neutral Agree Strongly Agree 18. Is your community safe, secure, and supportive? Strongly Disagree Disagree Neutral Agree Strongly Agree Thank you!
