Form - Vitality Survey

Please complete this form in one sitting. Incomplete forms cannot be saved.

Name*
First Last
Date of Birth*
Month
Day
Year
Today's Date*
Month
Day
Year
Please score each question from 0-4 (never-0, seldom-1, occasionally-2, often-3, very often-4)
How often do you...
Experience indifference (don't care)?
Lose your sense of humor/take life too seriously?
Experience doubt or indecision?
Experience worry and anxiety?
Feel overly cautious or pessimistic?
Lack self confidence or have low self esteem?
Experience stress or feel nervous or tense?
Feel irritable or oversensitive?
Experience difficulty concentrating and loss of clear thought?
Experience loss in adequate energy (fatigue)?
Use coffee, tea, tobacco, sugar or other stimulants as a pick-me-up?
Experience nervous indigestion?
Experience loss of sex drive?
Experience difficulty sleeping?
Experience difficulty getting up in the morning?
Feel run down?
Feel depressed?
Feel like crying for no reason?
Find it difficult to sit quietly (without fidgeting, talking, reading, watching TV, etc)?
Find it difficult to express your feelings?
Experience rapid heart beat or panic?
Feel moody?
Feel suicidal or wonder whether life is worth living?
Have anxiety about not having enough money?
Fear ill health?
Fear criticism?
Fear loss of love?
Fear old age or death?
Feel “something is the matter with me” but don’t know what?
TOTAL:*

Please score each question from 0-4 (never-0, seldom-1, occasionally-2, often-3, very often-4)