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Quality of Life Checkup

Helping people reflect on the way their life is going
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To assure you receive the results of your survey, please double check
the accuracy of your email address in the box below.

Name:
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Indicate how you're doing in each of the following key areas of your life
by selecting a number from 1 through 5 below each statement.

1. Is your weight about right?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
2. Are you eating a healthy, balanced diet?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
3. Do you limit your use of drugs?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
4. Are you exercising vigorously 3 to 4 times a week?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
5. Are you keeping your body toned by stretching daily?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
6. Are you getting enough rest and sleep?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
7. Do you express love and caring easily and frequently?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
8. Are you finding time to maintain your friendships?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
9. Are you dealing honestly with conflicts as they arise?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
10. Do you have a satisfying sex life?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
11. Do you have at least one relationship where you feel totally accepted?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
12. Do you feel sustained by your relationships?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
13. Are you reading enough good books?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
14. Are you informed about and involved in larger social and world issues?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
15. Are you exposing yourself to stimulating, new ideas?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
16. Does your lifestyle reflect your basic values?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
17. Do you take time periodically to reflect on the purpose of your life?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
18. Are you finding meaning in your life as a whole?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
19. Are you engaged in satisfying work?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
20. Are you pleased with the activities that capture most of your time?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
21. Are you making the kind of contribution to others you want to?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
22. Are you making good use of your talents?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
23. Are you having fun and enjoying your fair share of belly laughs?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
24. Are you content with what you've achieved thus far?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
25. Are you starting most days with energy and confidence?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
26. Do you feel good about your options and prospects?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
27. Do you have a support system that assists you in achieving your goals?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
28. Are you living mostly in the present as opposed to the past and future?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
29. Are you in control of your use of time?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
30. Are you coping well with the inevitable losses that come to all of us?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great

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