Self-Assessment
Instructions: Complete the following sections by thinking critically about your experiences and habits.
- Over the past seven days, how many MINUTES did you spend on each of the following activities?
- Engaging in leisurely reading:
- Engaging in leisurely Internet activities:
- Writing in a journal:
- Engaging in classroom educational activities (e.g., GED, college):
- Engaging in educational activities outside of the classroom (e.g., homework, report writing, research):
- Participating in recreational sports activities (e.g., soccer, basketball, softball):
- Participating in recreational fitness activities (e.g., running, weight lifting):
- Receiving a professional massage or engaging in whirlpool/water therapy:
- Attending religious services:
- Praying outside of religious services:
- Volunteering time to help a person or organization in need:
- Having face-to-face contact with family (e.g., spouse, children, parents, siblings):
- Communicating with family (e.g., phone, e-mail, video, chat):
- Communicating with friends (include contact with new friends):
- Communicating with a professional therapist (e.g., routine, post-trauma debriefs):
- Over the past seven days, how healthy was your diet?
- Enter the number of caffeinated drinks that you consumed over the past seven days:
- Enter the number of packs of cigarettes that you consumed over the past seven days:
- Enter the number of containers of smokeless tobacco that you consumed over the past seven days:
- Enter the total number of hours of sleep you have had for the past seven days:
- Over the past seven days, how have you dealt with anxiety?
- Have you used sleep medication during the past seven days?
- Have you used prescription medication to control stress or anxiety during the past seven days?
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