Plain City Burnout Survey 1.23.09

Age:

Age: 20's

30's

40's

50's

60's

70's

80's +

I have enough time to pursue my own interests & needs.

I have enough time to pursue my own interests & needs. True

False

I often take on more commitments than I can handle.

I often take on more commitments than I can handle. True

False

I say "no" when someone asks me to do something that I don't want to do.

I say "no" when someone asks me to do something that I don't want to do. True

False

I often feel guilty about all of the things that I am not doing.

I often feel guilty about all of the things that I am not doing. True

False

It is easier to give help than to accept help from others.

It is easier to give help than to accept help from others. True

False

I am comfortable expressing anger, frustration, and disappointment.

I am comfortable expressing anger, frustration, and disappointment. True

False

I have struggled at one time or another with emotional or mental health problems (depression, anxiety, low self-esteem, abuse, substance abuse, etc).

I have struggled at one time or another with emotional or mental health problems (depression, anxiety, low self-esteem, abuse, substance abuse, etc). True

False

Family members who have struggled with emotional problems.

Family members who have struggled with emotional problems. True

False

I get less than 7 hours sleep every night.

I get less than 7 hours sleep every night. True

False

I exercise at least 3 times per week for 1/2 hour.

I exercise at least 3 times per week for 1/2 hour. True

False

I am generally happy with my life and relationships.

I am generally happy with my life and relationships. True

False

I can easily accept compliments from others.

I can easily accept compliments from others. True

False

I am tired or worried most of the time.

I am tired or worried most of the time. True

False

I have sought professional counseling?

I have sought professional counseling? True

False

If true, for what issues

I have family members who have sought professional counseling.

I have family members who have sought professional counseling. True

False

If true, for what issues

I have considered going to counseling, but haven't followed through.

I have considered going to counseling, but haven't followed through. True

False

If true, what has prevented you from seeking help?

Plain City Burnout Survey 1.23.09
Exit this survey

1. Default Section

Age:

I have enough time to pursue my own interests & needs.

I often take on more commitments than I can handle.

I say "no" when someone asks me to do something that I don't want to do.

I often feel guilty about all of the things that I am not doing.

It is easier to give help than to accept help from others.

I am comfortable expressing anger, frustration, and disappointment.

I have struggled at one time or another with emotional or mental health problems (depression, anxiety, low self-esteem, abuse, substance abuse, etc).

Family members who have struggled with emotional problems.

I get less than 7 hours sleep every night.

I exercise at least 3 times per week for 1/2 hour.

I am generally happy with my life and relationships.

I can easily accept compliments from others.

I am tired or worried most of the time.

I have sought professional counseling?

I have family members who have sought professional counseling.

I have considered going to counseling, but haven't followed through.

The areas in my life that are the most emotionally draining for me are:

The thing I would most like to change my about myself is:

Plain City Burnout Survey 1.23.09Exit this survey

1. Default Section

Age:

I have enough time to pursue my own interests & needs.

I often take on more commitments than I can handle.

I say "no" when someone asks me to do something that I don't want to do.

I often feel guilty about all of the things that I am not doing.

It is easier to give help than to accept help from others.

I am comfortable expressing anger, frustration, and disappointment.

I have struggled at one time or another with emotional or mental health problems (depression, anxiety, low self-esteem, abuse, substance abuse, etc).

Family members who have struggled with emotional problems.

I get less than 7 hours sleep every night.

I exercise at least 3 times per week for 1/2 hour.

I am generally happy with my life and relationships.

I can easily accept compliments from others.

I am tired or worried most of the time.

I have sought professional counseling?

I have family members who have sought professional counseling.

I have considered going to counseling, but haven't followed through.

The areas in my life that are the most emotionally draining for me are:

The thing I would most like to change my about myself is:

Plain City Burnout Survey 1.23.09
Exit this survey