Wellness Questionnaire

In the past 12 months have you experienced:

	Yes	No
Death of Spouse/Partner?

Divorce?

Marital Separation?

Death of a Close Family Member?

Breakup of a Long-Term Relationship?

Major Injury or Illness?

Major Change in the Health or Behavior of a Family member?

Sexual Difficulties?

New family member (birth, adoption, someone moving in)?

Major change in personal financial status?

Death of a close friend or more distant family member?

Change to a different line of work?

Taking out a mortgage or a loan for a major purpose?

Major change in responsibilities at work (promotion/demotion, transfer)?

2. Choose the best answer that reflects how frequently you have experienced the following during the last month:

3. The next block of questions are to assess your stressors, and how you respond to stress in daily life, from work, home, and other social situations, to parenting and finances. For each block, visualize yourself in the specific scenario being presented, and then answer the questions.

	No stress	Little stress	Medium stress	High stress	Extreme stress
Think of your supervisor and think about any difficulties or tension in this relationship. Now indicate how you typically feel about this relationship.

	No stress	Little stress	Medium stress	High stress	Extreme stress
Think about any tension created by what your job demands from you and how much control you have over how you do your job. Now indicate how you typically feel about these aspects of your job.

	No stress	Little stress	Medium stress	High stress	Extreme stress
Think about how much effort you have to put into your job and how rewarded you feel in terms of salary benefits, promotion prospects, and your sense of being valued for your work.Now indicate how you typically feel about this.

	No stress	Little stress	Medium stress	High stress	Extreme stress
Bring to mind the faces of your co-workers and think about any difficulties or tension in your relations with them at work. Now indicate how you typically feel about your coworker relations.

	No stress	Little stress	Medium stress	High stress	Extreme stress
Now reflect on your work situation overall, and indicate the level of stress you typically feel.