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Do you feel that you maintain a balance between work and leisure? |
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Yes
No
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How many hours of sleep do you usually get? |
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6 hours or less
7 to 8 hours
9 hours or more
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Do you exercise regularly? (one or more times a week for at least 20 minutes) |
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Yes
No
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Do you usually eat 3 meals a day? |
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Yes
No
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How often have you been bothered by any illness, injury, pains or fears about your health during the past 3 months? |
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Frequently
Occasionally
Not at all
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Do you enjoy your current job? |
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Yes
Somewhat
No
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Do you have close friends, relatives or others you can talk to about personal matters and can call on for help when needed? |
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Almost always
Sometimes
Never
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How often do you have insomnia or trouble with falling asleep? |
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Rarely or never
Once or twice per month
One time per week
2 to 3 times per week
4 or more times per week
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In the past few months, have you been experiencing an uncomfortable amount of stress or pressure in your life? |
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Yes
No
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How much stress do you feel at work? |
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High level of stress
Moderate level of stress
Low level of stress |
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How much stress do you feel at home? |
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High level of stress
Moderate level of stress
Low level of stress
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How often do you recognize early, and prepare for, events or situations likely to be stressful for you? |
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Seldom or never
Sometimes
Often
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How often does your day include planned periods of relaxation? |
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Seldom or never
Sometimes
Often
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Do you practice any specific stress management techniques such as meditation, biofeedback, deep breathing or planned periods of relaxation? |
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Yes
No
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Do you feel that you manage your time effectively enough to avoid procrastination? |
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Yes
No
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Are you experiencing any major disappointments that are affecting your life? |
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Severely
Moderately
Slightly
Not at all
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Do your religious, spiritual or philosophical beliefs contribute to your happiness? |
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Yes, very much
Yes, somewhat
No
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How happy have you been with your life over the past six months? |
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Very happy
Somewhat happy
Neither happy nor unhappy
Somewhat unhappy
Very unhappy
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How often do you engage in activities you really enjoy? |
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At least once a day
At least once a week
At least once a month
Never
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Have you had any severe personal, emotional, behavioral or mental problems for which you needed help during the past year? |
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Yes
No
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If you had severe problems, did you seek professional help? |
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Yes
No
Have not felt I needed professional help
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How often do you take drugs or medication for headaches? (prescription, over-the-counter or other) |
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More than 4 times per week
2 to 4 times per week
1 time per week
Seldom
Never
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How often do you take drugs or medication to help you sleep? (prescription, over-the-counter or other) |
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More than 4 times per week
2 to 4 times per week
1 time per week
Seldom
Never
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How often do you take drugs that affect your mood or help you relax? (prescription, over-the-counter or other) |
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More than 4 times per week
2 to 4 times per week
1 time per week
Seldom
Never
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How often do you feel dependent upon coffee, tea or other caffeinated drinks to start the day or to keep you awake? |
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Often
Sometimes
Seldom
Never
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