Questionnaire Energy Management

First name and surname*

Birthday

Email address*

(in case you are (unexpectedly) unable to attend the presentation of your result, please leave your e-mail address)

Phone number*

(In case the email address is not working)

Sleep Score

Nutrition Score

Exercise Score

Humour Score

Passion Score

Relaxation Score

Social Life Score

Home Score

Professional Life Score

Sense of Purpose Score

Energizer Sleep

1.1 Sleep - I fall … directly asleep*

1.2 Sleep - I sleep on average … hours a night*

1.3 Sleep - In the morning I wake up ...*

Energizer Nutrition

2.1 Nutrition - I am able to manage to create a balanced and healthy meal ... per day*

2.2 Nutrition - I know which nutrients have a positive/negative effect on my health*

2.3 Nutrition - I drink on average …*

0 (I never drink alcohol)
1 glas alcohol per day
2 glasses alcohol per day
3 or more glasses alcohol per day
in the weekend (vr, za or zo) 1 glas alcohol per day
in the weekend (vr, za or zo) 2 glasses alcohol per day
in the weekend (vr, za or zo) 3 or more glasses alcohol per day

Energizer Exercise

3.1 Exercise – I exercise daily an average of… (with a slightly raised pulse)*

3.2 Exercise – My physical condition in the past two years has …*

3.3 Exercise - When I exercise, I … get injured*

Energizer Humour

4.1 Humour - When I am embarrassed in a public situation, I …. feel ashamed*

4.2 Humour - When I ask 4 friends if they think I’m humorous, I score a (1 = a bit, 5 = a lot)*

4.3 Humour - To have a good time, I am …. on others*

Energizer Passion

5.1 Passion – When I look back on my life so far, I think I live my passions...*

5.2 Passion – I know my inner drives…*

5.3 Passion – In …% of the time, I get influenced by the behavior and the emotions of other people*

You are half way, now comes the Energizer Relaxation

6.1 Relaxation – In the weekend I am completely recovered on ...*

6.2 Relaxation – I manage daily to relax physically and mentally (without distraction of tv etc.) …*

6.3 Relaxation – After a stressful period I know … what steps to take to get back into balance*

Energizer Social Life

7.1 Social life – I am … satisfied about the quality of my social contacts*

7.2 Social life – The balance of people that DRAIN my energy and that GIVE me energy is…*

7.3 Social life – Whenever I experience emotional problems, I can ... share these with the people in my surroundings*

Energizer Home

8.1 Home – Whenever I am at home, I have the feeling that I … relax*

8.2 Home - When I describe the atmosphere at home, I find this …*

8.3 Home – Whenever I think about moving, I would want to do that…*

Energizer Professional Life

9.1 Professional life – I experience … appreciation for the work I do*

9.2 Professional life- The past 2 years I am …% satisfied with the work I do*

9.3 Professional life - The future prospect of my current job is …*

Energizer Sense Of Purpose

10.1 Sense of purpose – I have … purpose in my life*

10.2 Sense of purpose – I … variety and challenge in my life*

10.3 Sense of purpose – When I look back, I can say that I until now … contributed to my own growth and that of others*

Mind&Health