CLIENT SELF ASSESSMENT Name * First Name Last Name Today's Date * MM DD YYYY Answer the following questions regarding each of the dimensions of health. Indicate how often you think the statements TRULY describe you. * PHYSICAL HEALTH 1) I maintain a healthy weight/body composition. Strongly Disagree Disagree Neutral Agree Strongly Agree 2) I eat healthy foods. Strongly Disagree Disagree Neutral Agree Strongly Agree 3) I do exercises designed to strengthen my muscles. Strongly Disagree Disagree Neutral Agree Strongly Agree 4) I wash my hands frequently. Strongly Disagree Disagree Neutral Agree Strongly Agree 5) I get 7-9 hours of sleep each night. Strongly Disagree Disagree Neutral Agree Strongly Agree 6) I exercise aerobically 30 or more minutes most days. Strongly Disagree Disagree Neutral Agree Strongly Agree SOCIAL HEALTH * 1) I participate in a wide variety of social activities. Strongly Disagree Disagree Neutral Agree Strongly Agree 2) I am considerate of other people's feelings. Strongly Disagree Disagree Neutral Agree Strongly Agree 3) I am a good listener. Strongly Disagree Disagree Neutral Agree Strongly Agree 4) I am shy and find it difficult in many social situations. Strongly Disagree Disagree Neutral Agree Strongly Agree 5) I have someone I can talk to about my feelings. Strongly Disagree Disagree Neutral Agree Strongly Agree 6) I cover my mouth when I sneeze or cough. Strongly Disagree Disagree Neutral Agree Strongly Agree EMOTIONAL HEALTH * 1) I find it easy to laugh about things that happen to me. Strongly Disagree Disagree Neutral Agree Strongly Agree 2) I avoid alcohol/drugs to forget about my problems. Strongly Disagree Disagree Neutral Agree Strongly Agree 3) I can express my feelings when I need to. Strongly Disagree Disagree Neutral Agree Strongly Agree 4) I tend to worry about things. Strongly Disagree Disagree Neutral Agree Strongly Agree 5) I recognize when I am stressed and take steps to relax. Strongly Disagree Disagree Neutral Agree Strongly Agree 6) I feel good about myself and like myself for who I am Strongly Disagree Disagree Neutral Agree Strongly Agree ENVIRONMENTAL HEALTH * 1) I use Styrofom and/or plastic plates, cups and utensils. Strongly Disagree Disagree Neutral Agree Strongly Agree 2) I reuse and recycle anything I can. Strongly Disagree Disagree Neutral Agree Strongly Agree 3) I smoke cigarettes. Strongly Disagree Disagree Neutral Agree Strongly Agree 4) I think about how many choices affect the environment. Strongly Disagree Disagree Neutral Agree Strongly Agree 5) I use both sides of the paper when taking notes. Strongly Disagree Disagree Neutral Agree Strongly Agree 6) I don't leave the water running when doing dishes, brushing my teeth, shaving & I don't take long showers. Strongly Disagree Disagree Neutral Agree Strongly Agree INTELLECTUAL HEALTH * 1) I tend to act impulsively without thinking of consequences. Strongly Disagree Disagree Neutral Agree Strongly Agree 2) I am able to think clearly to create solutions to problems. Strongly Disagree Disagree Neutral Agree Strongly Agree 3) I continually learn new things. Strongly Disagree Disagree Neutral Agree Strongly Agree 4) I consider my options before making a decision. Strongly Disagree Disagree Neutral Agree Strongly Agree 5) I ask questions when I don't understand, Strongly Disagree Disagree Neutral Agree Strongly Agree 6) I learn from my mistakes and act differently the next time the same situation arises. Strongly Disagree Disagree Neutral Agree Strongly Agree SPIRITUAL WELLNESS * Spiritual wellness is a sense of purpose, values and direction in one's life. 1) I believe that life is precious & think about what's important in life. Strongly Disagree Disagree Neutral Agree Strongly Agree 2) I take time to enjoy nature. Strongly Disagree Disagree Neutral Agree Strongly Agree 3) I take time to do the things I love. Strongly Disagree Disagree Neutral Agree Strongly Agree 4) I have faith in some kind of higher power. Strongly Disagree Disagree Neutral Agree Strongly Agree 5) I listen to my intuition and gut feelings. Strongly Disagree Disagree Neutral Agree Strongly Agree 6) I engage in acts of kindness. Strongly Disagree Disagree Neutral Agree Strongly Agree OCCUPATIONAL WELLNESS * 1) I enjoy my work/school experience most days. Strongly Disagree Disagree Neutral Agree Strongly Agree 2) I am able to maintain my personal values at work/school. Strongly Disagree Disagree Neutral Agree Strongly Agree 3) I am able to balance work/school with my family & personal life. Strongly Disagree Disagree Neutral Agree Strongly Agree 4) I manage my stress levels at work/school. Strongly Disagree Disagree Neutral Agree Strongly Agree 5) I feel my contributions are valued at work/school. Strongly Disagree Disagree Neutral Agree Strongly Agree 6) I am focusing on reaching my occupational/school goals. Strongly Disagree Disagree Neutral Agree Strongly Agree Thank you!