| |
|
Always
|
Sometimes
|
Never
|
| 1. |
I
eat at least one hot, balanced meal a day |
1 2
|
3
|
4 5
|
| 2. |
I
get seven to eight hours of sleep at least four nights a week |
1
2
|
3
|
4
5
|
| 3. |
I
give and receive affection regularly |
1
2
|
3
|
4
5
|
| 4. |
I
have at least one relative within 50 miles, on whom I can rely |
1
2
|
3
|
4
5
|
| 5. |
I
exercise to the point of perspiration at least twice a week
|
1
2
|
3
|
4
5
|
| 6. |
I
limit myself to less than half a pack of cigarettes a day |
1
2
|
3
|
4
5
|
| 7. |
I
take fewer than five alcoholic drinks a week |
1
2
|
3
|
4
5
|
| 8. |
I
am the appropriate weight for my height |
1
2
|
3
|
4
5
|
| 9. |
I
have an income adequate to meetbasic expenses |
1
2
|
3
|
4
5
|
| 10. |
I
get strength from my religious beliefs |
1
2
|
3
|
4
5
|
| 11. |
I
regularly attend club or social activities |
1
2
|
3
|
4
5
|
| 12. |
I
have a network of friends and acquaintances |
1
2
|
3
|
4
5
|
| 13. |
I
have one or more friends to confide in about personal matters |
1
2
|
3
|
4
5
|
| 14. |
I
am in good health (including eysight, hearing, teeth) |
1
2
|
3
|
4
5
|
| 15. |
I
am able to speak openly about my feelings when angry or worried |
1
2
|
3
|
4
5
|
| 16. |
I
have regular conversations with the people I live with about
domestic problems -- for example, chores and money |
1
2
|
3
|
4
5
|
| 17. |
I
do something for fun at least once a week |
1
2
|
3
|
4
5
|
| 18. |
I
am able to organize my time effectively |
1
2
|
3
|
4
5
|
| 19. |
I
drink fewer than three cups of coffee (or other caffeine-rich
drinks) a day |
1
2
|
3
|
4
5
|
| 20. |
I
take some quiet time for myself during the day |
1
2
|
3
|
4
5
|