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Assess your Quality of Life

Directions: Circle the number next to each statement that describes the statement as honestly and accurately as you can. If an item doesn’t apply, leave it blank.
When you are finished, add up the number of times you circled 1-3, 4-7, and 8-10. This will give you a good idea of how you view your Quality of Life.
Take special note of the areas that don’t measure up to your desires. Then make a list of items and areas you want to improve. For more ideas on how to use this information, please contact us by e-mail

CLICK HERE TO DOWNLOAD A PRINTABLE COPY OF THE SURVEY...


WORK: Not at all.....Somewhat.....Very much
1. My work is satisfying. 1 2 3 4 5 6 7 8 9 10
2. I like my work environment. 1 2 3 4 5 6 7 8 9 10
3. I work well with my co-workers. 1 2 3 4 5 6 7 8 9 10
4. I get along with my boss/subordinates. 1 2 3 4 5 6 7 8 9 10
5. I am being adequately compensated. 1 2 3 4 5 6 7 8 9 10
6. The benefits package is sufficient. 1 2 3 4 5 6 7 8 9 10
7. My working hours are satisfactory. 1 2 3 4 5 6 7 8 9 10
8. I feel stimulated and challenged. 1 2 3 4 5 6 7 8 9 10
9. My efforts/accomplishments are valued. 1 2 3 4 5 6 7 8 9 10
10. There is opportunity for advancement. 1 2 3 4 5 6 7 8 9 10
RELATIONSHIPS:
1. I am happy in my primary relationship. 1 2 3 4 5 6 7 8 9 10
2. I like the person I am with. 1 2 3 4 5 6 7 8 9 10
3. I like myself in this relationship. 1 2 3 4 5 6 7 8 9 10
4. I like being in a relationship. 1 2 3 4 5 6 7 8 9 10
5. Our differences are positive for the relationship. 1 2 3 4 5 6 7 8 9 10
6. My partner is growing and learning. 1 2 3 4 5 6 7 8 9 10
7. I am growing and learning. 1 2 3 4 5 6 7 8 9 10
8. We resolve our differences productively. 1 2 3 4 5 6 7 8 9 10
9. We can both share our deepest feelings. 1 2 3 4 5 6 7 8 9 10
10. My life is better for being in this relationship. 1 2 3 4 5 6 7 8 9 10
HEALTH:
1. I consider myself in good health. 1 2 3 4 5 6 7 8 9 10
2. I eat a healthy diet. 1 2 3 4 5 6 7 8 9 10
3. I allow myself some indulgence in food. 1 2 3 4 5 6 7 8 9 10
4. I follow an exercise program regularly. 1 2 3 4 5 6 7 8 9 10
5. I enjoy the exercising I do. 1 2 3 4 5 6 7 8 9 10
6. I am satisfied with my weight. 1 2 3 4 5 6 7 8 9 10
7. I take care of my health problems. 1 2 3 4 5 6 7 8 9 10
8. I have a positive attitude about my health. 1 2 3 4 5 6 7 8 9 10
9. I can manage my stress levels. 1 2 3 4 5 6 7 8 9 10
10. I am satisfied with my body image. 1 2 3 4 5 6 7 8 9 10
SPIRITUALITY AND RELIGION:
1. I like to observe the traditions of my religion. 1 2 3 4 5 6 7 8 9 10
2. I enjoy attending religious services. 1 2 3 4 5 6 7 8 9 10
3. My religion gives me comfort. 1 2 3 4 5 6 7 8 9 10
4. I am comfortable with my religious observance. 1 2 3 4 5 6 7 8 9 10
5. My spirituality is a positive factor in my life. 1 2 3 4 5 6 7 8 9 10
FRIENDS AND SOCIAL LIFE:
1. I have several friends I enjoy. 1 2 3 4 5 6 7 8 9 10
2. The amount of friends I have is sufficient. 1 2 3 4 5 6 7 8 9 10
3. The quality of my friendships is good. 1 2 3 4 5 6 7 8 9 10
4. I spend enough time with my friends. 1 2 3 4 5 6 7 8 9 10
5. My friendships are equally give and take. 1 2 3 4 5 6 7 8 9 10
6. I enjoy the social activities I engage in. 1 2 3 4 5 6 7 8 9 10
7. My social life is as busy as I like. 1 2 3 4 5 6 7 8 9 10
8. My friends add to my sense of well-being. 1 2 3 4 5 6 7 8 9 10
9. My social life adds value to my life. 1 2 3 4 5 6 7 8 9 10
10. My friends like each other. 1 2 3 4 5 6 7 8 9 10
MENTAL AND EMOTIONAL HEALTH:
1. I feel quite healthy mentally. 1 2 3 4 5 6 7 8 9 10
2. I can handle most of my emotions. 1 2 3 4 5 6 7 8 9 10
3. I keep my worries to a minimum. 1 2 3 4 5 6 7 8 9 10
4. I have minimal “moody” times. 1 2 3 4 5 6 7 8 9 10
5. I manage my anger appropriately. 1 2 3 4 5 6 7 8 9 10
6. I take responsibility for my actions. 1 2 3 4 5 6 7 8 9 10
7. I can hear and consider other’s views. 1 2 3 4 5 6 7 8 9 10
8. I feel confident about who I am. 1 2 3 4 5 6 7 8 9 10
9. I have a positive attitude towards others. 1 2 3 4 5 6 7 8 9 10
10. I have a positive attitude towards life. 1 2 3 4 5 6 7 8 9 10
GOALS AND DREAMS:
1. I have clear goals for my life. 1 2 3 4 5 6 7 8 9 10
2. My goals are reasonable and attainable. 1 2 3 4 5 6 7 8 9 10
3. I have a plan on how to accomplish my goals. 1 2 3 4 5 6 7 8 9 10
4. I am taking steps to reach my goals. 1 2 3 4 5 6 7 8 9 10
5. I have reached some of my goals. 1 2 3 4 5 6 7 8 9 10
6. My goals are in line with my dreams. 1 2 3 4 5 6 7 8 9 10
7. I allow myself to dream. 1 2 3 4 5 6 7 8 9 10
8. I can distinguish between dreams and reality. 1 2 3 4 5 6 7 8 9 10
9. My dreams are a positive factor in my life. 1 2 3 4 5 6 7 8 9 10
10. I believe in myself. 1 2 3 4 5 6 7 8 9 10
© 2003 Shelli Chosak / http://www.4AQualityLife.com