Wellness Checklist

Date:

First Name:*

Last Name:*

Email:*

A copy of this checklist will be sent to this email address in .pdf format.

Phone:

Street Address:

City:

State /Province/Region:

Zip/Postal Code:

I know my 4 biggest STRESS TRIGGERS. They include:

2.

3.

4.

I have SOMEONE to TALK to when my stress level is high.

YES
NO
SOMETIMES

People I can talk to when STRESS LEVELS are high: (Names not necessary unless volunteered. Can be listed as a friend, a sibling, a relation, a pastor, a therapist, etc)

2.

3.

I have a PLACE to WRITE THINGS DOWN when my stress level is high.

YES
NO

I have a way to RELAX:

YES
NO

I have HEALTHY FOOD on hand:

YES
NO
SOMETIMES

My HEALTHY FOODS include:

List as many as you have.

My APPETITE has significantly changed lately:

YES
NO

If YES , please describe the changes and why you think this is occurring:

On average, I get this many hours of SLEEP each night:

On average, my SLEEP PATTERNS are:

RESTFUL
INTERRUPTED

I am experiencing changes in my SLEEP HABITS lately. Changes include:

I am taking MEDICATION as prescribed:

YES
NO

I know what to EXPECT from my MEDICATION:

YES
NO

I have questions about my MEDICATION as it relates to Exercise and Nutrition:

I am involved in SOCIAL ACTIVITIES:

YES
NO
SOMETIMES

SOCIAL ACTIVITIES include:

My friends are aware of my NEEDS:

YES
NO
SOMETIMES

My NEEDS include:

I am considerate of the NEEDS of my FRIENDS:

YES
NO
SOMETIMES

Their NEEDS include:

I have a HOBBY or OTHER ACTIVITY where I feel comfortable:

YES
NO

Skills required for my HOBBY or OTHER ACTIVITY include:

Overall, I feel like I'm improving MY SKILLS required for the HOBBY or OTHER ACTIVITY:

YES
NO

I feel like sometimes my HOBBY or OTHER ACTIVITY requires more TIME than I can afford:

YES
NO

I feel like sometimes my HOBBY or OTHER ACTIVITY requires more MONEY than I can afford:

YES
NO

I feel the greatest sense of WELLBEING when I do this:

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