Wellness Checklist Quick lifestyle checklist. Once complete, we'll have a brief snapshot and follow-up with you. Date: MM slash DD slash YYYY First Name:(Required)Last Name:(Required)Email:(Required) 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:1 hour2 hours3 hours4 hours5 hours6 hours7 hours8 hours9 hours10 hours11 hours12 hoursOn 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:CAPTCHA Δ
