Mind&Health | Questionnaire energy management

First name and surname*

Birthday*

Score Slaap

Score Voeding

Score Bewegen

Score Humor

Score Passie

Score Ontspanning

Score Sociale contacten

Score Thuis

Score Werkleven

Score Zingeving

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 daily drink on average … glasses of alcohol*

0 (I never drink alcohol)
1 glass of alcohol per day
2 glasses of alcohol per day
3 or more glasses of alcohol per day
1 glass of alcohol per day on weekends (Fri, Sat or Sun)
2 glasses of alcohol per day on weekends (Fri, Sat or Sun)
3 or more glasses of alcohol per day on weekends (Fri, Sat or Sun)

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 ...*

fully recovered on Saturday morning
fully recovered on Saturday afternoon
fully recovered on Saturday evening
fully recovered on Sunday morning
fully recovered on Sunday afternoon
fully recovered on Sunday evening
not fully recovered on Sunday evening

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 at the end of my life, I can say that I … contributed to my own growth and that of others*