!

Personal Wellness Questionnaire & Plan

General Instructions
Whether the major focus of your life is being a student, working a job, or enjoying your
retirement – there are multiple areas of your life that contribute to the success of your major
focus. Those areas together make up your personal wellness.

The purpose of this questionnaire is to indicate your current profile of overall wellness and to
help you plan a foundation from which to build and strengthen your different areas of personal
wellness – to better support the major focus of your life.
INSTRUCTIONS: In each of the following 8 components of personal wellness, please indicate
how often the following statements apply to you. For the total score for each component, add
up the columns and enter the total of those.
Emotional - Having high self-esteem and confidence, satisfying relationships, a support
network, and staying optimistic.

Priority for Very little of Sometimes Most of the

Effort Statement the time time
(2 points)
(1 point) (3 points)

I have a well-developed sense of my x

own attitudes and values.
I average 7-8 hours of sleep daily. x
I find healthy ways to cope with stress x
(e.g., exercise, relaxation, social
support).
I am able to cope with feelings of x
sadness and worry.
I seek counseling if I face problematic or x
enduring emotional difficulties in my life.
Total Total Score of all three columns: 0 6 6
Score

Financial - Maintaining a balanced budget for expenses while also practicing money-saving
techniques. Preparedness for all expenses, including short-term, long-term, and emergencies.

Priority for Very little of Sometimes Most of the

Effort Statement the time time
(2 points)
(1 point) (3 points)
I budget my funds so that I do not run x
out of money.
I balance my checkbook regularly. x
I know my total amount of debt. x

Page !1 of 7
!
 I have 1 or no credit cards (debit cards x
not included).
I am never late on payments. x
I put money into savings on a regular x
basis.
I have at least 10% of my annual income x
in an interest earning savings account.
Total Total Score of all three columns: 2 2 15
Score

Intellectual - Getting the most out of life by asking questions, being open to new ideas, learning
new skills, and studying effectively.
Priority for Very little Sometimes Most of
Effort Statement of the time the time
(2 points)
(1 point) (3 points)

I look for ways to learn more about a x

variety of things.
I take on challenges as a chance to x
learn.
I am curious about things. x
I am creative. x
I try to improve myself. x
I do something several times a week to x
work my brain, such as puzzles,
studying, or hobbies.
I read. x
Total Score Total Score of all three columns: 2 1 12

Physical – Maintaining optimal health by getting enough sleep, eating healthy, exercising, and
avoiding unhealthy habits.

Priority Very little of Sometimes Most of the

for Effort Statement the time time
(2 points)
(1 point) (3 points)

I am active at least 20-30 x

minutes two to three days a
week.
I maintain healthy eating x
patterns.
I eat at least 5 servings of fresh x
fruits and vegetables daily.

Page !2 of 7
!
 I drink zero to no more than 1 x
drink a day (women) or 2 drinks
a day (men).
I avoid harmful use of drugs x
(includes tobacco, marijuana,
alcohol, etc.).
I practice safe sex (e.g. use a x
condom, partners test negative
for STIs) or practice abstinence.
I see a health care practitioner if x
I can't solve a health concern on
my own.
I manage my weight in healthy x
ways.
Total Total Score of all three 2 21
Score columns:

Social – Having a supportive social network, contributing to society, and valuing cultural
diversity.
Priority for Very little Sometimes Most of
Effort Statement of the time the time
(2 points)
(1 point) (3 points)

I am satisfied with my social life. x

I am involved in at least one group (ie civic x
club, church, sports team, etc.)
I maintain a network of supportive friends/ x
family/social contacts.
I have a least one meaningful relationship. x
I am accepting of the diversity of others x
(i.e. race, religion, gender, ability, etc.).
I give priority to my own needs by saying x
“no” to others’ request of me when
applicable.
Total Total Score of all three columns: 2 2 9
Score

Spiritual – Possessing a set of guiding beliefs, principles, or values that give meaning and
purpose to life, having a clear understanding of right and wrong, seeing the beauty in life and
finding joy in everyday life. Spiritual wellness is also the capacity to love, have compassion for
others, forgiveness, joy, and fulfillment.

Priority Very little of the Sometimes Most of the

for Statement time time
(2 points)
Effort
(1 point) (3 points)

Page !3 of 7
!
 I have a belief system (e.g., x
spiritual, atheist).
I have a sense of purpose in my x
life.
I take time for spiritual growth/ x
development.
I utilize resources to improve my x
well-being.
I spend time reflecting and x
meditating.
Total Total Score of all three 0 2 12
Score columns:

Time Management – Managing time smartly to have more time to do the things we want to do.
Priority Very little of the Sometimes Most of the
for Statement time time
(2 points)
Effort
(1 point) (3 points)

I plan some “me time” each day. x

I use a prioritized list of “Things x
to Do”.
I begin my day with a plan of x
action.
I keep the different areas of my x
life in balance.
I keep my life’s “stuff” organized. x
Total Total Score of all three 0 4 9
Score columns:

Work (paid or unpaid) – The ability to get personal fulfillment from our work while still
maintaining balance in our lives. Our desire to contribute to make a positive impact on the
organizations we work in and to society as a whole.

Priority Very little of Sometimes Most of the

for Statement the time time
(2 points)
Effort
(1 point) (3 points)

I spend some time each week x

doing a job, volunteer or service
work, or work at home, such as
chores or hobbies.
I am developing the necessary x
skills to achieve my work goals.

Page !4 of 7
!
 I have confidence in my skills to x
do the work I want.
I work effectively with others. x
I know where to find work to do x
that I am interested in doing.
Total Total Score of all three 0 0 15
Score columns:

TOTAL WELLNESS SCORE: Add up your scores for all 8 components of wellness to give you
your total wellness score.
PRIORITY FOR EFFORT: It is common for people to have some areas in which they are well
much of the time, some areas in which they are well some of the time, and some areas in which
they are well very little or none of the time. As you look back at your scores in the different
areas, note the areas in which you indicated “very little of the time.” Pick one of these in each of
the 8 wellness components to prioritize your efforts for improvement. If you were well enough in
a component that your lowest scores were “sometimes,” then choose one of these response
areas as a priority for attention.
NOW you are ready to develop your Personal Wellness Plan.
FOLLOW-UP PLAN: Complete the following for each priority area that you indicated.
Area to work on:
____Emotional_________________________________________________________

Things I can to do When will you How often What resources do you need to
make this start doing will you do get to help you this (money,
improvement. this? this? people, etc.)?
Meditate to have a well- Sunday, Feb, Every None
developed sense of my 27, 2022 evening/
own attitudes and morning for
values. about 10
min
Sleep more throughout Monday, Feb, Every Night None
the week to make sure I 28, 2022
am getting 7-8 hours
asleep.
Create ways to better Sunday, Feb, Every None
cope with stresses 27, 2022 weekend

Area to work on:

______Financial_______________________________________________________

Things I can to do When will you How often What resources do you need to
make this start doing will you do get to help you this (money,
improvement. this? this? people, etc.)?

Page !5 of 7
!
Create a financial plan Sunday, Feb, Weekly Professional financial advisor
that allocate money to 27, 2022 for assistance
my savings on a more
regular basis

Area to work on:

___Intellectual__________________________________________________________

Things I can to do When will you How often What resources do you need to
make this start doing will you do get to help you this (money,
improvement. this? this? people, etc.)?
Read more books Monday, 1 book per Books
March 7, 2022 month
Do more puzzles and Monday, Challenging Puzzles
things that challenge March 7, 2022 puzzle/per
my brain week

Area to work on:

____Social_________________________________________________________

Things I can to do When will you How often What resources do you need to
make this start doing will you do get to help you this (money,
improvement. this? this? people, etc.)?
Say no to more thing ASAP Whenever None
when I don’t have the my mental
capacity. and social
meter is full.
Become more involved End of School Monthly Information to community
within my community. Semester involvement.

Area to work on:

_____Spiritual________________________________________________________

Things I can to do When will you How often What resources do you need to
make this start doing will you do get to help you this (money,
improvement. this? this? people, etc.)?
Meditate more often Sunday, Feb, Every None
27, 2022 evening/
morning for
about 10
min

Page !6 of 7
!
Area to work on: _______Time
Management______________________________________________________

Things I can to do When will you How often What resources do you need to
make this start doing will you do get to help you this (money,
improvement. this? this? people, etc.)?
Create a way to Sunday, Feb, Weekly Organizer app/planner
prioritize and organize 27, 2022
my life.

Page !7 of 7
!