Wellness Evaluation of Lifestyle

Forms

The Wellness Evaluation of Lifestyle (WEL) measures 19 dimensions of

wellness. It is based on the traits of healthy persons. The purpose of the WEL is t
help you make healthy lifestyle choices. Your results can help you develop a plan~0
live your life more fully.

INSTRUCTIONS
The wellness items are statements that describe you. Answer each item in a
way that is true for you most of the time. Think about how you most often see
yours~/(, feel, or behave. Answer all the 134 items_on the WEL. Do not spend too
much time on any one item. Your honest answers will make your scores more useful,

The_choices for each item are Strongly Agree, Agree, Undecided, Disagree, and
Strongly Disagree. Circle the letter on the answer sheet that most closely matches ho
you see yourself. For example, suppose you "like meeting new people" most of the w
time. You would circle "Agree" or "Strongly Agree" for this item as shown below.

I like meeting new people.

Strongly Agree Undecided Disagree Strongly
Agree Disagree
A B C D E

Begin by filling in the following information:

Last Name:
---- ---- ---- ---- ---
First Name:
---- ---- ---- ---- ---
Ge,nder:
Grade Level: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Birth Date:
Identification Number (if instructed): ------------

. WELL Sampler, © 2001, 2004 Jane E. Myers, Thomas J. Sweeney, & J. Melvin Witmer.
· All Rights Reserved. Published by Mind Garden, Inc., www.mindgarden.com
-24-
 .
Evaluation of Lifestyle Quest·1onna1re
wellness
Forms

e t th at
ng items, circle the letter that repres n s e statement below th
h of the follo wi
or eac f you·
;sFmost true o .

A Strongly Agree
8. Agree
utral
C. Undecided or Ne
D. Disagree
E. Strongly Disagree
A 8 C D E
nt part of my life.
s u r e activities are an importa
0 E
A 8 C
D
with ho w I co pe with stress.
I am satisfie d
2. car. A 8 C D E
we ar m y se at be lt when riding in a
1most always
3.
d in a serious task. A 8 C D E
wh en en ga ge
mor even
4. 1frequently see hu
A 8 C D E
ga l dr ug s.
1avoid the use of ille

-
5. A 8 C D E
ot he rs wi th re sp ect to my gender.
pport from
6. Generally I feel su
ers. A 8 C D E
at em ba rra ss es oth
mor th
7. Sometimes I use hu
A 8 C D E
lim it m y co ns um ption to no more
ohol or
8. I avoid the use of alcday.
o drinks pe r
than tw
y sa tisfying. A 8 C D E
fin d pe rs on all
activities which I
9. I engage in leisure A 8 C D E
unique person .
10 . I value myself as a A 8 C D E
m y ev en tual de at h.
at peace with
11 . I have come to be m e if I we re in A 8 C D E
ing for
would do most anyth
12. I have friends who A 8 C D E
need. ria te ly bo th m y po sitive and negative
s approp
13. I am aqle to expres A 8 C D E
feelings. r m e, it wi ll.
wrong fo
14. If something can go rk an d my leisure . A 8
C D E
ee n m y wo
the balance betw
15 . I am satisfied with

lvin Witmer.
Sweeney, & J.,Me
1, 2004 a
J_ ne E. My~rs, Thomas J. w.mindgarden ·.com
200 ., ww
WELL sampler,. © ved . Published by Mind Garden, Inc
All Rights Reser -25-
 A. Strongly Agree
B. Agree
c. Undecided or Neutral
D. Disagree
E. Strongly Disagree

16. I do not use tobacco. A

17. My cultural heritage enhanc
es the quality of my life. A B C t
D
18. The work I do allows me to
make use of my abilities and A B C
t
skills. D
19. I have had a mystical or pea
k experience in which I felt a A B C
t
of inner peace and timeliness sense D
. t
20. I am able to manage my stre
ss. A B C D
21 . I usually don't have enough t
energy to get through the day A B
22.
. C "o -t
I make time for leisure activiti
es which I enjoy. A B C D
23 . I can take charge and manag E
e a situation when it is approp A B C
riate. D E
24. I am able to laugh at myself.
A B C D
25. I am able to cope with my neg
E
ative emotions. A B C D
26 . E
My gender affects the quality
of my life positively. A B C D
27. I recognize the early signs of E
my mental and physical stress. A B C D
28. I am a lonely person. E
A B C D
29. I look forward to the work I E
do each day. A B C D E
30. When I need information, I
have friends whom I can ask
for help. A B C D E
31. My needs for physical touch
and closeness are being met.
32. A B C D E
I eat three meals a day includ
ing breakfast.
33.
A B C D E
I a~ often disappointed bec
ause my expectations are not
met. A B C D E
34. My finances are adequate to
support my current lifestyle.
35. I am often misunderstood by
A B C D E
others.
A B C D E
36. Overall, I am a happy person
37. A B C D E
I am able to find creative sol
utions to difficult problems.
38. A B C D E
I have\ friends and/or relative
s who would provide help for
were in need. me if I A B C D E
39. I engage in a leisure time act
ivity in which I lose myself and
seems to stand still. time A B C D E
40. I am satisfied with the quality
and quantity of food in my die
t. A B C D E
WELL Sampler,© 2001, 200
4 Jane E. MyE:rs, Thomas J.
All Rights Reserved. Publishe Sweeney,_& J. Melvin Witmer.
d by Mmd Garden, Inc., www
.mmdgarden.com
-26-
 A. Strongly Agree
B. Agree
C. U~decided or Neutral
D. Disagree
E. Strongly Disagree

of my . .
rnY physical appearance in spite imperfections A B C D E
ccePt ·
I8 ·ttle time for leisure activities. A B C D E
&1- I t,ave 11 . d I' . itual pra crices.
. ipate in organize re 1g1ous or spir A B C D E
,z. 1part1c gs
suallY aware of how I feel about thin . A B C D E
JS. I arTl u .
to reduc e my stress.
k positive experiences every day A B C D E
4>1· 1 see
•oy regular physical activity. A B C D E
I ell)
clusions which affe B C D E
I rTlake assumption_s or jump to con be untrue ct me
A
gatively, and which turn out to
l being. · B C D E
~:rn s.~tisfied with my spiritual wel A
48, ings . A B C E
usually am not in touch with my feel
D
1
49. eously. A B C D E
arn able to express my feelings spontan
1
50. A B C D E
~ satisfied with my leisure activities.
• A B C D E
I daily see k aI goo d laugh through means such as th e comrc
52. d t · ·
strips an e ev1s1on programs . . T A B C D E
1 am able to experience
a full range of human emotions , pos1 ive
53, and negative. E
A B C D
1 believe that I am a wor
thwhile person.
54, A B C D E
I am satisfied with my sexual life.

-
55. C D E
A B
elopment.
ote little or no time to my spiritual dev
56. I dev A B C D E
my stress.
I can cha nge how I look at things to reduce
57. . A B C D E

manage my anger.
58. I a07 able to A B C D E
d by almost everyone I
It is important for me to be liked or love
59. A B C D E
meet. whom I have a
I hav e at least one person in my life with
60. ship.
significant positive emotional relation

J. Melvin Witmer.
E. My~rs, Thomas J. Sweeney,. &
WELL sampler ,© 2001 , 2004 Jane en, Inc., www.m1ndgar den.com
by Mind Gard
All Rights Reserved. Published -27-
 A. Strongly Agree
B. Agree
C. Undecided or Neutra 1
o Disagree
e: Strongly Disagree
. h. s with others, that I am A B C
D E
61 . I feel that I am genuine in my relations ip
"real " and that I can be "me: A B C D
62.
I

I eat a nutritionally balanced diet.

•
E
A B C D
63.
·
I often put myself down when 1make mistakes. E
. .
· . . . wledge and skills m A B C D
64. I am effective in using my imagination, kn_o E
•
making choices to solve problems in my l~fe_. erested in my A B C D
65. I have at least one person in my life who is int E

66.
growth and well being. t ss
I am able to cope with the thoughts that cause me s re ·
A B C
De
A B C D E
67. I have spiritual beliefs which guide me in my daily life.
A B C D E
68. I have at least one person who helps me to sustai·n an optimistic,
hopeful orientation to life during good times a_nd ~ad.
69. A B C D E
I initiate and maintain friendships that are satisfying to me.
B C D E
-
70. A
I gain little satisfaction from my work.
71. I use humor to gain new perspectives on the contradictions and A B C D E
predicaments of life.
72. When appropriate, I can put my work aside for leisure activities A B C D E
without feeling guilty about it.
73. Much of my life is determined by factors outside my direct A B C D E
control.
74. I must be competent, adequate, and achieving in most things to A B C D E
consider myself worthwhile.
75. I feel a positive identity with others of my gender. A B C D E
76 . . Most 9f the time I can handle any workload expected of me. A B C D E
77. I fir:id myself uncomfortable in the presence of others who are A B C D E
spiritually, racially, or culturally different from myself.
78. I have had an experience in which I felt a sense of oneness with A B C D E
nature, the universe, or a higher power.
79. I am seldom embarrassed because of my cultural heritage. A B C D E
80. I like myself in spite of my imperfections. A B C -D E

WELL Sampler, © 2001, 2004 Jane E. Myers, Thomas J. Sweeney, & J. Melvin Witmer.
All Rights Reserved. Published by Mind Garden, Inc., www.mindgarden .com
-28-
 A. Strongly Agree
B. Agree
C. Undecided or Neutral
D. Disagree
E. Strongly Disagree
. ore physical symptoms that may require medic
IdO . a1 A B C
D E
10
81. 8uen~ ~isruptions to my sleep patterns.
avoid
1 A B C D
·der myself to be an active person. E
I cons1 . . A B C D
~- find myself feeling sad without knowing why E
often
1 · A B C D
all the work I do is not very stressful E
over , · A B C D E
ain appreciated by those with whom I work.
1 A B C D E
1
regularly eng~ge !n creative activities which are mentally and
rnotionally satisfying. - A B C D E
e f
MY perception o events .1s usually different from that of others.
58, A B C D E
believe in the existence of a power greater than myself.
89, 1 A B C D E
_ 1make it~ point to..seek the views of others through media,
90 A B C D E
conversation, reading, or other activities.
D" am a very shy person.
A B C D E
92 . I pace myself so I do not get too stressed .
A B C D E
g3. I tend to trust others until I have reason to do otherwise. A B C D E
94. I have a great deal of control over conditions affecting the work I A B C D E
do. .
95. My spiritual growth is an essential lifelong journey. A B C D E
96. I experience a sense of awe and wonder with each new day. A B C D E
97. I am able to understand the feelings of others without being A B C D E
judgmental.
98. I usually don't look on the bright side of things. A B C D E
99 . . · I do some form of stretching activity at least three times per A B C D E
week;>, -
100. 1have at \east one intimate relationship that is secure and A B C D E
lastin .

WELL SampIer, © 2001 ' 2004 Jane E. Myers ' Thomas J. Sweeney,. &·J. Melvin
d
Witmer.
All Rights Reserved. Published by M_~i-Garden, Inc., www.mindgar en.corn
 A. Strongly Agree
B. Agree
c. Undecided or Neutral
D. Disagree
E. Strongly Disagree

101. 1strive to meet my purpose and goals in life through planfulness.

102. I have at least one person in whom I can confide my thoughts A B
and feelings. . . C
D
103. I seek ways to stimulate my thinking and increase my learning. A B
C
104. I usually achieve my goals I set for myself. A B D
C
105. I have difficulty accepting my shortcomings. A B D
C
106. Prayer, meditation, or individual spiritual study is a regular part D
A B
C
t
of my life. D
107. I have at least one person whose company I never tire of, even
A B t
though we spend a great deal of time together each week. C D
108. When .seeking solutions, I gather information, study the choices,
A B
t
and evaluate the possible outcomes before taking action. C D
109. My cultural identity is a source of satisfaction and pride to me. t
A B
C D
110. I participate in physical activity through work or leisure at least t
A B
three times a week for at least 20 minutes each time. C D
111. Being a male/female is a source of satisfaction and pride to me. E
A B C
112. I do not get regular dental check-ups. D E
A B C
113. I am responsible for keeping other people happy. D E
A B C
114. I have sources of support with respect to my race, color or D E
culture. A B C
D E
115. I eat a variety of food including fresh fruits, vegetables
and
whole grains daily. ' A B C
D E

WELL Sa~pler, © 2001 , 2004 Jane E M

All Rights Reserved. Published by ~homas J. Sweeney, & J. Melvin Witmer.
8rd en, Inc., www.mindgarden.com
-30-
---- A.
B.
C.
D.
E.
Strongly Agree
Agree
Undecided or Neutral
Disagree
Strongly Disagree

A B C D E
~ I am able to relax when I need to do so to reduce my stress.
B C D E
ov·erall, I am satisfied with my life. A
117.
B C D E
I have not had my share of happiness in life up to now. A
118.
A B C D E
119. Others describe me as having a good sense of humor.
A B C D E
120. I am il')terested in the needs of others.
A B C D E
121. My diet includes an adequate amount of vitamins, minerals, and
fiber.
A B C D E
122. It is important for me to be physically fit.
A B C D E
123. Overall, I am a healthy person.

Continue on the next page

WELL Sampler,© 2001, 2004 Jane E. Myers, Thomas J. Sweeney, & J. Melvin Witmer.
All Rights Reserved. Published by Mind Garden, Inc., www.mindgarden.com
-31-
 124- Do you live alone?
A. Yes B. No
125. What is your current marital status?
A. Married/Partnered
B. Single
C Separated
D. Divorced
E. Widowed
126. What is your current employment status?
A. Employed full-time
B. Employed part-time
C. Retired, not working
D. Retired, working part-time
E. Not working
127. Are you currently a student?
A. Yes, in high school
B. Yes, working on undergraduate degree
C. Yes, working on graduate degree
D. Yes, taking courses for fun
E. No, not currently a student
128. What is the highest level of education you have completed?
A. Less than high school
B. High school graduate
C. Trade/technical school
D. Associate degree
E. Bachelor's Degree
F Master's degree
G. Specialist degree (e.g., Ed.S., CAS)
H. Professional degree (e.g., DDS, JD, MD)
I. Doctorate degree (e.g., Ph.D., Ed.D.)
129. What is your current occupation?
A. Farming, forestry, or fishing
B. Managerial and professional specialty
C. Operators (machine, transportation, assemblers, laborers)
D. Precision production, craft, and repair operations
E. Service occupations (e.g., hairdresser, food, beverage, law enforcement, armed forces enlist d)
F. Technical, sales, and administrative support ' e
G. Student
H. Other
130. What is the ethnic/cultural background with which you most closely identify?
A. American Indian/Native American
B. Alaskan Native
C. Asian or Pacific Islander
D. African American
E. Caucasian
F. Latino/Latina
G. Other
131. What is the approximate size of the community in which you live?
A. Rural, less than 2,500 persons
B. Small town, 2,500-15,000 persons
C. Mid-size town, 15,000 - 50,000 persons
D. Large town, 50,000 -100,000 persons
E. Metropolitan area, over 100,000 persons

WELL Sampler, © 2001, 2004 Jane E. Myers, Thomas J. Sweeney, & J. Melvin Witmer.
All Rights Reserved. Published by Mind Garden, Inc., www.mindgarden.com
-32-
 Wellness Evaluation of Lifestyle
Form S
Scoring Key

Raw Scores:
All items are reverse scored except for the following:
Reverse Scored Negative Scored ( Items 33, 47, 59, 73,
74,88, 113
A=5 . A=1
8=4 8=2
C=3 C=3
0=2 D=4
E=1 E=5
Add up the reverse scores to get a raw score for each of the Life Tasks and/or its
sub-tasks.

Percentage Scores:
Divide the raw score by the maximum possible score (total number of items x 5
points) for each of the Life Tasks and/or its sub-tasks.
Multiply the results to get the percentage score.

Distracter Items:
The following 17 items serve as distracter items and are not included in the
scoring:
Items 7, 14, 21, 28, 35, 42, 49, 56, 63, 70, 77, 84, 91, 98, 105, 112, 118

Life Task I -- Spirituality

Item Numbers 11 19 43 48 67 78 89 95 96 106

Add Scores _ +_ +_ +_ +_ +_ +_ + +- +-

Raw Score= - -
[(Raw Score I 50) x 100] = Percentage Score = _ _

Life Task II -- Self-Regulation

Sense of Worth
Item Numbers 10 41 54 61 80
Add Scores - +
- +
- +
- +
-
Raw Score= - -
[(Raw Score I 25) x 100] = Percentage Score = _ _

WELL Sampler,© 2001, 2004 Jane E. Myers, Thomas J. Sweeney, & J. Melvin Witmer.
All Rights Reserved. Published by Mind Garden, Inc., www.mindgarden.com
-33-
Sense or Control
101
·---~ ·-···_?~neg .. ....~~········ ······· ······· ·
-- ---Numb
--Item --- -..23
--.... --ers -- ---
+- +_ ...
Add Scores _ +_ +-
Raw Score . . ·-...
[(Raw Score / 25) x 100) = PercentageS '
cor e~" '
Realistic Beliefs
Item Numb ers 33neg 47neg
-- ----- ---- ------ --- -- - ---- -- ----
+_ +_ +_ +_ +_
.. ...~).~!!~.~........ "'
···· ..
Add Scores •..
Raw Score
-
-.
[(Raw Score/ 30) x 100) = Percentage score~ ,
. . . .
Emotional Responsiveness
!!~.f"!l.. ..~~···· ..25...... ~~···....?~ ...... .......~~········..... . "'
Add Scores _ +_ +_ +_ +_ +_
Raw Score:::
.......
[(Raw Score/ 30) x 100) = Percentage Score:::---.....
---............
Intellectual Stimulation
Item Numbers..37 ...... ~?. ......~9...... ~-~~-·····~9.~
.............. ...... ....... .
+- +- +-
Add Scores +
- - Raw Score:::

Sense of Humor
24
Item Numbers --4---- -------
---- ---- .. ---. -----
52
-------- ------
71
[(Raw Score/ 25) x 100) = Percentage Sco re::-

119
-.

--- ---.. - --·-

--
--
+ +- +- +-
Add Scores - - Raw Score::
[(Raw Score/ 25) x 100] = Percentage Score::
Nutrition
Item Numbers 32 40 62 115 121 -- -- - ---. - -- -- -. ·- ·------
-- -- ---- --. -- . - ------ ------ -------- --- -- -
--
Add Scores +- +- +- +-
- Raw Score=
re= _
[(Raw Score/ 25) x 100) = Percentage Sco

as J. Sweeney, & J. Melvin Witmer.

WELL Sampler, © 2001, 2004 Jane E. Myers, Thom
All Rights Reserved. Published by Mind Garden, Inc., www.mindgarden.com
-34-
Exercise
Item N~~-~~-~~--~~------~-~---.. ----99--·----·--- 122-------- ----- ----------- - -- .. --- ---- - -· -- ................ .
110----------
--
----· --
Add Scores _ +_ +
- +- +- Raw Sco re=_
[(Raw Score/ 25) x 100] = Percentage Sco re=_
self-Care
_-~--------~-------~ --------~~------ 81 _----· 82 -· -· _-- ---- ---· --- _. -·. _-- ------ ---- ----- --
Add Scores _ +_ +
- +
- +
- +
- Raw Sco re=_
[(Raw Score/ 30) x 100] = Percentage Sco re=_
Stress Management
57 66 92 116
s 2 20 27 45
- -- ---- -- ---- -- ---- ----------- -- -- -- ----- . ---- ... ----- ---------- ------
Item Number -- -- ------- --------- -- -- --- ------- ------ -- --
Add Scores + + + + + + +
- - - - - - - Raw Scor e=_

[(Raw Score/ 40) x 100] = Percentage Sco re=_

Gender Identity
111
------ ---- -- --------------- ------- --- -- -- -- ---- ------- ------ - -------- ----
26
Item Numbers 6-- --------- 75
---------------------
Add Scores _ +_ +_ +_
Raw Sco re=_
[(Raw Score/ 20) x 100] = Percentage Score = _ _
Culture Identity
Item Number s 17 79 109 114
-- - ---- ----- -- - -- --- --- ------- ----.. ------ -- --------- -- --- -- -- - --- --
• .
.... -- .... -- -- -- -- ------ -- -- ------- ----- ..
+- +- +-
.Add Scores - Raw Score = _ _
[(Raw Score/ 20) x 100] =Percentage Score =__

Melvin Witmer.
WELL Sampler,© 2001, 2004 Jane E. Myers, Thomas J. Sweeney, & J.
m
All Rights Reserved. Published by Mind Garden, Inc., www.mindgarden.co
-35-
Life-Task Ill -Work & Leisure
Work
Item Numbers 15 ... ).~...... ~~·······~·····.!.?....... ...... .... 94 .. __
-- ----- --- ------ --- ---- -
+- +- +- +- +
Add Score s_+_ +_ -
Raw Score:::
[(Raw Score/ 40) x 100] = Percentage Score::: ---------

Leisure
Item Numbers 9 22 .. .... --~1...... 72 ··········· ---------
.... + + + +
Add Score s_+_ - - - -
Raw Score:::
[(Raw Score/ 30) x 100] = Percentage Score ::: ..._____
Life Task IV•· Friendship
Item Numbers 12 30 .....~~·······?·~· ·····~~...... . ~?. .....).?~ .......... ------
-------------- --------------------
Add Scores _+ _+_ +- +- +- +-
Raw Score::
[(Raw Score I 35) x 100] = Percentage Score :: --.
Life Task V •· Love
Item Numbers
-------······· 31 ...~~······~9-... '. ..?.~ ......
········----
......1~g.....).g~ .....~9-?.......
---
Add Scores +_ +_ +_ +_ +_ +_ + _

---
- Raw Score ::
[(Raw Score I 40) x 100] = Percentage Score ::

TOTAL SELF-REGULATION
Add up the raw scores for all of the sub-tasks in Life Task 11 - Self-Regulation
Total Self-Regulation Raw Score=
[(Total Raw Score/ 320) x 100] = Total Percentage Score= _
-
PERCEIVED WELLNESS
-Item Numbers 36 117 123

Add Scores _ +_ +_

Raw Score= _
[(Raw Score/ 15) x 100] = Percentage Score= _

, WELL Sampler,© 2001, 2004 Jane E. Myers, Thomas J. Sweeney, & J. Melvin Witmer.
All Rights Reserved. Published by Mind Garden, Inc., www.mindga rden.com
-36-
TOTAL WELLNESS
Add up the raw scores from each of the Life Tasks to get a Total Wellness Raw
Score
Life Task 1 - Spirituality Raw Score= _ _ (10 items)
Life Task 2 - Total Self-Regulation Raw Score= _ _ (64 items)
(14 items)
Life Task 3 - Work & Leisure Raw Score= +
-----
=
Life Task 4 - Friendship Raw Score= _ _ (7 items)
Life Task 5- Love Raw Score= _ _ (8 items)

Total Wellness Raw Score=

[(Raw Score/ 515) x 100] = Total Wellness Percentage Score= - -

WELL Sampler,© 2001, 2004 Jane E. Myers, Thomas J. Sweeney, & J. Melvin Witmer.
All Rights Reserved. Published by Mind Garden, Inc., www.mindgarden.com
-37-