PROCARE — General Wellness Assessment

Confidential General Wellness
Assessment

**RECOGNIZE THE RISK AREAS IN YOUR LIFE**

Form with Scores

Date: Organisation: Branch/area: Organisation Position:

The purpose of this assessment is to identify possible risk areas in your life. This is not a test, so there is no right or wrong answer. You don't have to complete all sections, but you must answer all 5 questions in the sections you choose to complete.

Section 1: Self-esteem I feel self-conscious:
I feel people do not enjoy my company:
I feel I get pushed around:
I feel incompetent:
I feel ugly:

Section 2: Stress I feel that I am losing control of my life:
I feel that I am near breaking point:
I feel that I cannot keep up with all the demands on me:
I feel tense:
It is hard for me to relax:

Section 3: Emotional People tell me I have a bad temper:
I think about ending my life:
I feel depressed:
I feel nervous or anxious:
I feel I cannot control my anger:

Section 4: Habit Forming Behaviour Some of my habits (drinking, drugs, smoking, vaping, gambling, gaming, social media, other habit forming behaviours) are causing problems in my life:
Some of the habits or substances (mentioned above) help me calm my nerves or make me feel better:
Sometimes I have to use medication or energy drinks to cope or to make me feel better:
People tell me I should stop unhealthy habits in my life:
I have problems with a loved one who has unhealthy habits or suffers from addiction:

Section 5: Health & Lifestyle I worry about my health:
I have unprotected sex:
I avoid exercise:
I experience problems with sleeping or eating:
People tell me I should take better care of myself:

Section 6: Work I hate my job:
I feel my employer does not care about me:
I feel that I do not get along with my colleagues:
I feel very behind in my work:
I cannot stand my boss:

Section 7: Socio-economic I worry about my family / children / loved ones:
I worry about my financial position:
I experience problems with my children / friends / family:
I feel unhappy in my current environment:
I feel unsafe:

Section 8: Married or Romantic Relationship We experience sexual problems:
We experience problems with trust, jealousy or infidelity:
We argue / fight a lot:
We experience problems with children / parents / family / friends:
I feel that our relationship should be better:

Section 9: Parenting I find it difficult to discipline my child or children:
My child or children show signs of uncontrollable behaviour:
I find it difficult to handle conflict or disagreements with my child or children:
I find it difficult to communicate with my child or children:
I feel I meet my child or children’s needs adequately: