1.My husband or wife is my best friend.

Yes

No

2.How well are your eating habits and overall diet? 

I eat regular meals each day. 

I snack on healthy items like fruit and nuts.

I drink too much alcohol.

I have gained or lost excess weight this year. 

My doctor has expressed concerns about my diet. 

3.How well do you cultivate your activities related to entertainment, recreation and leisure? 

Very high quality

High quality

Neither high nor low quality

Low quality

Very low quality

4.How well is your relationship with your spouse, partner, or special friend?

Very easy

Easy

Neither easy nor difficult

Difficult

Very difficult

5.How well do you sleep?

I sleep soundly each night. 

I awaken feeling fresh each morning. 

There is a lot weighing on my mind that causes me to lose sleep. 

I like my bedroom and it is one of my preferred living spaces in my home.

I feel lonely in my bed. 

My bedtime routine and sleep hygiene are neither established nor relaxing. 

I feel nurtured & happy in my bed.

I am concerned about my sleeping habits.

I have a memory of a bad experience in my present or a past bed.

I regret an experience with someone I invited in my bed. 

I am not comfortable talking about past negative experiences in my bed. 

I feel confident to say "no" to people who wish to be in my bed with me. 

I trust my feelings about my preferences in bed.

6.I prefer to travel with

Partner and spouseBest friend other than partner or spouseGroups of friendsOther couplesMyself

7.How well is your relationships with most of your friends? 

Very easy

Easy

Neither easy nor difficult

Difficult

Very difficult

8.How well do I take of my body and exercise?

I have a regular physical health and exercise program.

I am in good shape for my age.

I enjoy moving my body. 

I feel breathless when I walk a short distance. 

I take responsibility for how I feel in my body. 

My doctor is worried about my heart health. 

I feel responsible in my sexual relationships and sexual health. 

I find sex to be a chore and unsatisfying. 

In truth, I would prefer not to have sex with my partner, and he or she is aware of this. 

9.How well do you get along with your peers or colleagues at work? 

A great deal

A lot

A moderate amount

A little

None at all

10.How well is my spiritual health?

I believe in God or a higher power and pray regularly. 

I am spiritual but not religious.

I prefer to volunteer or do random deeds of service then to belong to an institution of religion.

I pray each day.

Religion has been a source of problems in my family. 

I no longer practice the religion of my childhood.

I believe that my spiritual health is a part of my overall wellbeing.

I do not think it is important to believe in a higher power. 

11.How well is your financial or economic health? 

Extremely valuable

Very valuable

Somewhat valuable

Not so valuable

Not at all valuable

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