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* 1. How many 8 ounce glasses of soft drinks do you drink on an average per day?

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* 2. Rate the importance to me of consuming healthy food and drinks most of the time:
1 (not very important) and 10 (very important)

1 10
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 3. How well do you feel you are coping with your current stress load?

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* 4. How many hours of sleep do you get on average?

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* 5. During the past 4 weeks, to what extent have you accomplished less than you would have liked in your work or other daily activities as a result of emotional issues, such as feeling depressed or anxious?

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* 6. The next questions are about how you feel things have been with you during the past 4 weeks.
For each question, please give the one answer that comes closest to the way you have been feeling.
1. None of the time 2. A little of the time 3. Some of the time 4. A good bit of the time 5. All the time

  1 2 3 4 5
How much of the time during the past four weeks have you felt calm and peaceful?
How much of the time during the past four weeks did you have a lot of energy?
How much of the time during the past four weeks have you been a happy person?
How much of the time during the past four weeks did you take the time to relax and have fun daily?
How much of the time during the past four weeks did you feel confident and capable?

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* 7. Do you have any questions? Or is there something else you want your coach to know?

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