logo Partners for Strong Communities

Quality of Life Checkup

To assure you receive the results of your survey, please double check the accuracy of your email address in the box below.

Name:
E-mail:

Indicate how you're doing in each of the following key areas of your life by selecting a number from 1 through 5 below each statement.
1. Is your weight about right?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
2. Are you eating a healthy, balanced diet?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
3. Do you limit your use of drugs?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
4. Are you exercising vigorously 3 to 4 times a week?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
5. Are you keeping your body toned by stretching daily?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
6. Are you getting enough rest and sleep?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
7. Do you express love and caring easily and frequently?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
8. Are you finding time to maintain your friendships?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
9. Are you dealing honestly with conflicts as they arise?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
10. Do you have a satisfying sex life?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
11. Do you have at least one relationship where you feel totally accepted?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
12. Do you feel sustained by your relationships?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
13. Are you reading enough good books?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
14. Are you informed about and involved in larger social and world issues?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
15. Are you exposing yourself to stimulating, new ideas?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
16. Does your lifestyle reflect your basic values?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
17. Do you take time periodically to reflect on the purpose of your life?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
18. Are you finding meaning in your life as a whole?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
19. Are you engaged in satisfying work?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
20. Are you pleased with the activities that capture most of your time?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
21. Are you making the kind of contribution to others you want to?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
22. Are you making good use of your talents?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
23. Are you having fun and enjoying your fair share of belly laughs?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
24. Are you content with what you've achieved thus far?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
25. Are you starting most days with energy and confidence?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
26. Do you feel good about your options and prospects?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
27. Do you have a support system that assists you in achieving your goals?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
28. Are you living mostly in the present as opposed to the past and future?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
29. Are you in control of your use of time?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great
30. Are you coping well with the inevitable losses that come to all of us?
1 2 3 4 5
Ashamed To Say Need Major Tuneup Need Modest Change Need Fine Tuning Doing Great

Note: Please wait a moment after clicking on "submit" to be sure your responses were transmitted. All items must be completed in order to have a successful transmission.