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If 5 represents your best possible life, and 0 represents your worst possible life, where do you feel you stand at this time?
0 1 2 3 4 5
 
 
 
To what degree did you feel some or all of the following feelings yesterday – physical pain, worry, sadness, stress, anger?
Very Low Low Neutral High Very High
 
 
 
In the last week, how often did you eat fruits or vegetables?
Never Once a week Twice a week Three times a week At least 4 times a week
 
 
 
To what degree are you treated with respect
Very Low Low Medium High Very High
 
 
 
In the last week, did you learn or do something interesting?
Disagree Somewhat disagree Neutral Somewhat agree Agree
 
 
 
How often do you take substances (such as prescription items, alchohol, or illicit drugs) that impair your ability to function normally ?
Several times a day Daily Several times a week Weekly Less than once a week
 
 
 
To what degree do you worry about money
Very high High Medium Low Very Low
 
 
 
I know what is expected of me at work
Strongly disagree Somewhat disagree Neutral Somewhat agree Strongly agree
 
 
 
I have materials and equipment I need to do my work right
Strongly disagree Somewhat disagree Neutral Somewhat agree Strongly agree
 
 
 
My supervisor(s) seems to care about me as a person
Strongly disagree Somewhat disagree Neutral Somewhat agree Strongly agree