Emotional Wellness Assessment
Name
First Name
Last Name
1. My current stress level
1
2
3
4
5
6
7
8
9
10
Good
Bad
1 is Good, 10 is Bad
How Often
None
A Little
Moderate
Quite a bit
Extremely
2. Feeling overwhelmed or out of control
1
2
3
4
5
6
7
8
9
10
Good
Bad
1 is Good, 10 is Bad
How Often
None
A Little
Moderate
Quite a bit
Extremely
3. I don't like how my body looks
1
2
3
4
5
6
7
8
9
10
Good
Bad
1 is Good, 10 is Bad
How Often
None
A Little
Moderate
Quite a bit
Extremely
4. Feeling depressed, sad, or hopeless
1
2
3
4
5
6
7
8
9
10
Good
Bad
1 is Good, 10 is Bad
How Often
None
A Little
Moderate
Quite a bit
Extremely
5. Feelings of anxiety
1
2
3
4
5
6
7
8
9
10
Good
Bad
1 is Good, 10 is Bad
How Often
None
A Little
Moderate
Quite a bit
Extremely
6. Feelings of low self-esteem or self-worth
1
2
3
4
5
6
7
8
9
10
Good
Bad
1 is Good, 10 is Bad
How Often
None
A Little
Moderate
Quite a bit
Extremely
7. Negative self-talk
1
2
3
4
5
6
7
8
9
10
Good
Bad
1 is Good, 10 is Bad
How Often
None
A Little
Moderate
Quite a bit
Extremely
8. Feeling angry, bitter, or resentful
1
2
3
4
5
6
7
8
9
10
Good
Bad
1 is Good, 10 is Bad
How Often
None
A Little
Moderate
Quite a bit
Extremely
9. Feelings of failure
1
2
3
4
5
6
7
8
9
10
Good
Bad
1 is Good, 10 is Bad
How Often
None
A Little
Moderate
Quite a bit
Extremely
10. Feelings of shame
1
2
3
4
5
6
7
8
9
10
Good
Bad
1 is Good, 10 is Bad
How Often
None
A Little
Moderate
Quite a bit
Extremely
11. Perfectionism
1
2
3
4
5
6
7
8
9
10
Good
Bad
1 is Good, 10 is Bad
How Often
None
A Little
Moderate
Quite a bit
Extremely
12. Trouble sleeping
1
2
3
4
5
6
7
8
9
10
Good
Bad
1 is Good, 10 is Bad
How Often
None
A Little
Moderate
Quite a bit
Extremely
13. Feeling irritated or annoyed
1
2
3
4
5
6
7
8
9
10
Good
Bad
1 is Good, 10 is Bad
How Often
None
A Little
Moderate
Quite a bit
Extremely
14. Feeling restless, keyed up or on edge
1
2
3
4
5
6
7
8
9
10
Good
Bad
1 is Good, 10 is Bad
How Often
None
A Little
Moderate
Quite a bit
Extremely
15. Feeling very upset when reminded of a stressful event
1
2
3
4
5
6
7
8
9
10
Good
Bad
1 is Good, 10 is Bad
How Often
None
A Little
Moderate
Quite a bit
Extremely
16. Little interest or pleasure in doing things
1
2
3
4
5
6
7
8
9
10
Good
Bad
1 is Good, 10 is Bad
How Often
None
A Little
Moderate
Quite a bit
Extremely
17. Feeling tired or having little energy
1
2
3
4
5
6
7
8
9
10
Good
Bad
1 is Good, 10 is Bad
How Often
None
A Little
Moderate
Quite a bit
Extremely
18. Trouble concentrating during tasks or activities
1
2
3
4
5
6
7
8
9
10
Good
Bad
1 is Good, 10 is Bad
How Often
None
A Little
Moderate
Quite a bit
Extremely
19. Repeating disturbing dreams of memories or experiences
1
2
3
4
5
6
7
8
9
10
Good
Bad
1 is Good, 10 is Bad
How Often
None
A Little
Moderate
Quite a bit
Extremely
20. Feeling abandoned
1
2
3
4
5
6
7
8
9
10
Good
Bad
1 is Good, 10 is Bad
How Often
None
A Little
Moderate
Quite a bit
Extremely
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