Arlington EAP



609600332740ARLINGTON EAP WELLNESS ASSESSMENT00ARLINGTON EAP WELLNESS ASSESSMENTThe EAP is committed to promoting health and well-being for all employees. This confidential Wellness Assessment is designed to help you and your EAP professional identify any concerns which may impact your well-being. Please take a few minutes to answer the questions below.Name: ___________________________________Date: __________________________General Well-BeingOn an average day how would you rate your overall well-being?1 2 3 4 5 6 7 8 9 10 (highest)Do you have any chronic illnesses?YesNoIf so, do you have a good plan for managing them?YesNoDo you get at least 6 and half hours sleep most nights?YesNoDo you have close family or friends that you connect with regularly?YesNoDo you have safe, comfortable living environment?YesNoDo you ever have thoughts about harming yourself or others?YesNoDo you feel depressed (persistent feelings of sadness, hopelessness)?YesNoDo you experience anxiety (fear, worry that interferes with daily activities)?YesNoDo you keep firearm(s) in your home?YesNoIf yes, are they kept in a locked box or cabinet? YesNoHow would you rate your feelings of loneliness or isolation? 12345678910 (highest)How much have COVID-19 concerns increased your current stress level or any pre-existing symptoms?12345678910 (highest)How would you rate your financial well-being (consider concerns about your ability to make ends meet every month and your ability to comfortably retire by age 70)?12345678910 (highest)Stress Did you like your job?YesNoSomewhatDo you have good relationships with your boss and co-workers? YesNo SomewhatOn an average day how would you rate your level of stress?1 2 3 4 5 6 7 8 9 10 (highest)How would you rate the effectiveness of your personal strategies for coping with your stress?12345678910 (highest)Do you practice:MindfulnessDeep Breathing Stretching YogaOther Relaxation Methods? ________________________________________How do you manage your stress?_________________________________________________________________________________________________________________________________________________________________________Exercise(Circle the most accurate answer to the questions below)Do you exercise at least 30 minutes: 1 – 2 times a week3 – 5 times a weekdaily?Do you participate in sports activities: 1 – 2 times a week3 – 5 times a weekdaily?Nutrition(Circle the most accurate answer to the questions below)1.? Do you eat > 5 or more portions of a variety of fresh/frozen fruits and vegetables daily?YesNo2. Does your daily main meal always contain a good-sized serving of protein-rich food?(Serving is 4 oz., animal/plant e.g. meat, fish, eggs, vegetarian (beans, peas, lentils), nuts, seeds, tofu.)YesNo3. On average do you have two or more servings of dairy foods or fortified soy replacement per day?(Serving is 6.7 oz. of milk, yogurt, non or low-fat cheese.)YesNo4. Do you eat two or more portions of fish per week including at least one that is oily? Yes No (Oily fish are mackerel, herring, sardines, salmon, trout, fresh tuna.)5. Do you eat some nutrient-rich complex carbohydrates every day?YesNo (Potatoes with skins; wholegrain cereal/bread/pita; brown rice not white rice; whole-wheat pasta)6. Do you eat a healthy (low in sugar and fat) breakfast every day?YesNoSomewhat7. How many 8 oz. glasses of water do you drink every day?_____8. How many cups of coffee or other caffeinated beverages do you drink daily?_____9. How many sodas do you drink daily?_____10. How often did you have a drink containing alcohol in the past year? Never ( 0 ) Monthly or less ( 1 )Two to four times a month ( 2 ) Two to three times a week ( 3 )Four or more times a week ( 4 )11. How many drinks containing alcohol did you have on a typical day when you were drinking in the past year?1 or 2 drinks ( 0 )3 or 4 ( 1 )5 or 6 ( 2 ) 7 to 9 ( 3 )10 or more ( 4 )12. How often did you have six or more drinks on one occasion in the past year?Never ( 0 )Less than monthly ( 1 )Monthly ( 2 )Weekly ( 3 )13. Have you used recreational drugs in the past ten years?YesNo14. What substances have you used? ___________________________________________________15. What substances do you currently use? ______________________________________________16. How often do you use? Never ( 0 ) Monthly or less ( 1 )Two to four times a month ( 2 ) Two to three times a week ( 3 )For or more times a week ( 4 )17. How often do you smoke tobacco? Never 1-3 daily 4-6 daily Pack a dayIs there anything you would like to change about your health?__________________________________________________________________________________________________________________________________________________________________________To support employee health and well-being the EAP offers mindfulness and stress management classes as well as access to a variety of resources. We encourage annual physicals, flu shots, participation in annual health assessments and biometric screenings as well as open communication with your providers. Consider using online self-assessments to better understand your moods and their impact on your well-being. Remember that telehealth resources are available.Please visit for more information and links to resources.Let us know how we can support you.Rev. 9-2020 ................
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