90 day Fitness and Wellness Assessment

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Personal Information

First Name(Required)

Last Name

Email(Required)

Phone

Address(Required)

City(Required)

State(Required)

Zip(Required)

Quality of Life Assessment

Quality of Life Enjoyment and Satisfaction Questionnaire – Short Form

Taking everything into consideration, during the past week how satisfied have you been with your………

physical health?(Required)

mood?(Required)

work?(Required)

household activities?(Required)

social relationships?(Required)

family relationships?(Required)

leisure time activities?(Required)

ability to function in daily life?(Required)

sexual drive, interest and/or performance?*(Required)

economic status?(Required)

living/housing situation?*(Required)

ability to get around physically without feeling dizzy or unsteady or falling?*(Required)

your vision in terms of ability to do work or hobbies?*(Required)

overall sense of well being?(Required)

medication?

How would you rate your overall life satisfaction and contentment during the past week?(Required)

DISCLAIMER

THE ASSESSMENT ASSIGNED BY THE CBP ENDEAVORS WORKFORCE WELLNESS PROGRAM WILL BE COMPLETED AGAIN IN 90 DAYS. THE INFORMATION CONTAINED IN THE ASSESSMENT IS FOR THE DETERMINATION OF YOUR HEALTH AND WELLNESS USE ONLY AND WILL REMAIN CONFIDENTIAL

Pain and Stress Evaluation

What is your average physical pain level?(Required)

Highest physical pain level last 7 days?(Required)

What is your stress level today?(Required)

Highest stress level in last 7 days?(Required)

Feel about your overall fitness?(Required)

Rate your current energy level?(Required)

How would you rate your flexibility?(Required)

How would you rate your sleep?(Required)

Do you feel you get enough sleep at night?(Required)