Name
*
First Name
Last Name
Email
*
I have the motivation to realize my goals.
Most of the time
Often
Sometimes
Rarely
Almost Never
I like learning new things.
Most of the time
Often
Sometimes
Rarely
Almost Never
I eat a healthy balanced diet that makes me feel energized.
Most of the time
Often
Sometimes
Rarely
Almost Never
I make sure I get enough vitamins.
Most of the time
Often
Sometimes
Rarely
Almost Never
I avoid eating fast food
Most of the time
Often
Sometimes
Rarely
Almost Never
I avoid excess sugar.
Most of the time
Often
Sometimes
Rarely
Almost Never
I eat meat LESS than three times a week.
Most of the time
Often
Sometimes
Rarely
Almost Never
I drink LESS than three cups of coffee or tea a day.
Most of the time
Often
Sometimes
Rarely
Almost Never
I feel good about what I do (studies, job, being a full-time mother/father, etc.).
Most of the time
Often
Sometimes
Rarely
Almost Never
I drink LESS than 5 oz (three drinks) of alcohol per week.
Most of the time
Often
Sometimes
Rarely
Almost Never
I smoke LESS than 1 pack of cigarettes per week (less than 3 a day).
Most of the time
Often
Sometimes
Rarely
Almost Never
During my usual day, I am physically active (I take the stairs instead of the elevator, I walk).
Most of the time
Often
Sometimes
Rarely
Almost Never
During my usual day, I take time to stretch and to relax.
Most of the time
Often
Sometimes
Rarely
Almost Never
I exercise at least once a week.
Most of the time
Often
Sometimes
Rarely
Almost Never
Once I get to bed, I fall asleep easily.
Most of the time
Often
Sometimes
Rarely
Almost Never
To ease my aches and pains, I prefer natural remedies to medication.
Most of the time
Often
Sometimes
Rarely
Almost Never
I have a check-up exam at least once every three years.
Most of the time
Often
Sometimes
Rarely
Almost Never
I am happy with my weight.
Most of the time
Often
Sometimes
Rarely
Almost Never
I use drugs no more than once a month or never.
Most of the time
Often
Sometimes
I have a happy and healthy sex life.
Most of the time
Often
Sometimes
Rarely
Almost Never
I am aware of the occupational hazards my job involves (stress, pain, fatigue, etc.) and I take preventive measures.
Most of the time
Often
Sometimes
Rarely
Almost Never
I wake up feeling rested and have a sufficient amount of energy for the day.
Most of the time
Often
Sometimes
Rarely
Almost Never
I am satisfied with my relationships (friendships, love).
Most of the time
Often
Sometimes
Rarely
Almost Never
I have a mindfulness/meditation practice that I do daily
Most of the time
Often
Sometimes
Rarely
Almost Never
I am satisfied with the way I spend my leisure time.
Most of the time
Often
Sometimes
Rarely
Almost Never
