Striving for Balance Survey

1. Thank you for taking a moment to complete our brief survey.

1. Please choose your sex:

Please choose your sex: Male

Female

2. Please choose your age range:

Please choose your age range: 18 - 25

26 - 32

33 - 44

45 - 55

56 - 65

66 +

3. Please let us know how many children you have:

Please let us know how many children you have: None

4. Please choose your marriage status:

Please choose your marriage status: Single

Married

Divorced

Widowed

5. Tell us your occupation:

Tell us your occupation:

6. Choose your work schedule:

Choose your work schedule: Full-time

Part-time

Retired

Homemaker

Other

7. Of the life elements listed below, please rate the most demanding (1) of your time and energy on a daily basis to least demanding (9). (You do not have to choose all of them.)

Of the life elements listed below, please rate the most demanding (1) of your time and energy on a daily basis to least demanding (9). (You do not have to choose all of them.) Increased work pressure
Children
Partner
Home
Family Relationships (Ex. aging parents, relatives, etc)
Friends
Leisure/Self time
Pets
Other

8. Please rate your ability to balance the multiple life factors stated in the prior question:

Please rate your ability to balance the multiple life factors stated in the prior question: Excellent

Good

Fair

Poor

9. Based on the last 30 days, please rate your overall level of stress relative to these demands:

Based on the last 30 days, please rate your overall level of stress relative to these demands: High

Average

Low

10. Coping skills are a diverse set of activities that recharge your battery. Please rate how effective you are in using your coping skills to help you deal with life stressors.

Coping skills are a diverse set of activities that recharge your battery. Please rate how effective you are in using your coping skills to help you deal with life stressors. Excellent

Good

Fair

Poor

11. How do these life stressors affect your sex drive?

How do these life stressors affect your sex drive? Very much

Somewhat

Not at all

12. How do you think these life stessors affect your nutrition and ability to eat well-balanced meals vs. fast food?

How do you think these life stessors affect your nutrition and ability to eat well-balanced meals vs. fast food? Very much

Somewhat

Not at all

13. How do these life stressors affect your sleep habits?

How do these life stressors affect your sleep habits? Very much

Somewhat

Not at all

14. Please add any comments you would like to share here.

Please add any comments you would like to share here.

Striving for Balance SurveyExit this survey

1. Thank you for taking a moment to complete our brief survey.

1. Please choose your sex:

2. Please choose your age range:

3. Please let us know how many children you have:

4. Please choose your marriage status:

5. Tell us your occupation:

6. Choose your work schedule:

7. Of the life elements listed below, please rate the most demanding (1) of your time and energy on a daily basis to least demanding (9). (You do not have to choose all of them.)

8. Please rate your ability to balance the multiple life factors stated in the prior question:

9. Based on the last 30 days, please rate your overall level of stress relative to these demands:

10. Coping skills are a diverse set of activities that recharge your battery. Please rate how effective you are in using your coping skills to help you deal with life stressors.

11. How do these life stressors affect your sex drive?

12. How do you think these life stessors affect your nutrition and ability to eat well-balanced meals vs. fast food?

13. How do these life stressors affect your sleep habits?

14. Please add any comments you would like to share here.

Striving for Balance Survey
Exit this survey