Checklist and Personal Assessment test page for proof of concept

Assess Yourself: How Healthy Are You?

This page is not affiliated with OTTAWA WEST COMMUNITY SUPPORT in any way, this form is the initiative of the
Blair House blog to promote use of this translation technology and is an example of the capabilities that it provides.

How to use this form to submit to O.W.C.S. aging in place program or medical professionals.

  1. Select Language of your choice fill out the form in your preferred language and Save.(Ctrl + S) for html backup.
  2. After completing the form select print (Ctrl + P) choose save as PDF for copy in Your selected Language.
  3. Now go back to form select the Show original button (Ctrl + P) choose save as PDF for copy in English.
  4. This time rename to your name and send as attachment in an email in an English version or other Language.

Assess Yourself: How Healthy Are You?

 
By completing the following assessment, you will have a clearer picture of health areas in which you excel and those that could use varying degrees of work. Taking this assessment will also help you to reflect on various components of health that you may not have thought much about.
Use the results from this assessment as a guide and as a way to begin analyzing potential areas for improvement and/or maintenance. Answer each question, then total your score for each section. Your scores will appear in the Personal Checklist at the end of the assessment for a general sense of your health profile. Think about the behaviors that influenced your score in each category. Would you like to change any of them? Choose the area that you'd like to improve, then complete the Behavior Change commitment. Use the commitment to work through your struggles and implement a behavior change.
Each of the categories in this questionnaire is an important aspect of the total dimensions of health, but this is not a substitute for the advice of a qualified health care provider. Consider scheduling a thorough physical examination by a licensed physician or setting up an appointment with a mental health counselor at your building if you think you need help making a behavior change.
 
Instructions:
For each of the following, indicate how often you think the statements describe you.
 
Key
1Never
2Rarely
3Some of the Time
4Usually or Always
PHYSICAL HEALTH
I am happy with my body size and weight. 1  2  3  4  
I engage in vigorous exercises such as brisk walking, jogging, swimming, or running for at least 30 minutes per day, 3-4 times per week. 1  2  3  4  
I do exercises designed to strengthen my muscles and increase endurance at least 2 times per week. 1  2  3  4  
I do stretching, limbering up, and balance exercises such as yoga, pilates, or tai chi to increase my body awareness and control and increase my overall physical health. 1  2  3  4  
I feel good about the condition of my body and would be able to respond to most demands placed upon it. 1  2  3  4  
I get at least 7-8 hours of sleep each night. 1  2  3  4  
I try to add moderate activity to each day, such as taking the stairs instead of the elevator and walking whenever I can instead of riding. 1  2  3  4  
My immune system is strong and my body heals itself quickly when I get sick or injured. 1  2  3  4  
I have lots of energy and can get through the day without being overly tired. 1  2  3  4  
I listen to my body; when there is something wrong, I try to make adjustments to heal it or seek professional advice. 1  2  3  4  
    TOTAL:     

SOCIAL HEALTH
When I meet people, I feel good about the impression I make on them. 1  2  3  4  
I am open, honest, and get along well with other people. 1  2  3  4  
I participate in a wide variety of social activities and enjoy being with people who are different than I. 1  2  3  4  
I try to be a "better person" and work on behaviors that have caused problems in my interactions with others. 1  2  3  4  
I get along well with the members of my family. 1  2  3  4  
I am a good listener. 1  2  3  4  
I am open and accessible to a loving and responsible relationship. 1  2  3  4  
I have someone I can talk to about my private feelings. 1  2  3  4  
I consider the feelings of others and do not act in hurtful or selfish ways. 1  2  3  4  
I try to see the good in my friends and do whatever I can to support them and help them feel good about themselves. 1  2  3  4  
    TOTAL:     

EMOTIONAL HEALTH
I find it easy to laugh, cry, and show emotions like love, fear, and anger and try to express these in positive, constructive ways. 1  2  3  4  
I avoid using alcohol or other drugs as a means of helping me forget my problems. 1  2  3  4  
When viewing a particularly challenging situation, I tend to view the glass as "half full" rather than "half empty" and perceive problems as opportunities for growth. 1  2  3  4  
When I am angry, I try to let others know in nonconfrontational and nonhurtful ways, trying to resolve issues rather than stewing about them. 1  2  3  4  
I try not to worry unnecessarily and try to talk about my feelings, fears, and concerns rather than letting them become chronic issues. 1  2  3  4  
I recognize when I am stressed and take steps to relax through exercise, quiet time, or other calming activities. 1  2  3  4  
I feel good about myself and believe others like me for who I am. 1  2  3  4  
I try not to be too critical and/or judgmental of others and to understand differences or quirks that I may note in others. 1  2  3  4  
I am flexible and adapt or adjust to change in a positive way. 1  2  3  4  
My friends regard me as a stable, emotionally well-adjusted person whom they trust and rely on for support. 1  2  3  4  
    TOTAL:     

ENVIRONMENTAL HEALTH
I am concerned about environmental pollution and actively try to preserve and protect natural resources. 1  2  3  4  
I buy recycled paper and purchase biodegradable detergents and cleaning agents whenever possible. 1  2  3  4  
I recycle my garbage, purchase refillable containers when possible, and try to minimize the amount of paper and plastics that I use. 1  2  3  4  
I try to wear my clothes for longer periods between washing to reduce water consumption and the amount of detergents in our water sources. 1  2  3  4  
I vote for pro-environment candidates in elections. 1  2  3  4  
I write my elected leaders about environmental concerns. 1  2  3  4  
I turn down the heat and wear warmer clothes at home in winter and use the air conditioner only when necessary or at higher temperatures in summer. 1  2  3  4  
I am aware of lead pipes in my living area, chemicals in my carpet, and other potential hazards and try to reduce my exposure whenever possible. 1  2  3  4  
I use both sides of the paper when writing notes or doing assignments. 1  2  3  4  
I try not to leave the faucet running too long when I brush my teeth, shave, or shower. 1  2  3  4  
    TOTAL:     

SPIRITUAL HEALTH
I believe life is a precious gift that should be nurtured. 1  2  3  4  
I take time to enjoy nature and the beauty around me. 1  2  3  4  
I take time alone to think about what's important in life-who I am, what I value, where I fit in, and where I'm going. 1  2  3  4  
I have faith in a greater power, be it a God-like force, nature, or the connectedness of all living things. 1  2  3  4  
I engage in acts of caring and goodwill without expecting something in return. 1  2  3  4  
I feel sorrow for those who are suffering and try to help them through difficult times. 1  2  3  4  
I look forward to each day as an opportunity for further growth and challenge. 1  2  3  4  
I work for peace in my interpersonal relationships, in my community, and in the world at large. 1  2  3  4  
I have a great love and respect for all living things, and regard animals, etc., as important links in a vital living chain. 1  2  3  4  
I go for the gusto and experience life to the fullest. 1  2  3  4  
    TOTAL:     

INTELLECTUAL HEALTH
I carefully consider my options and possible consequences as I make choices in life. 1  2  3  4  
I learn from my mistakes and try to act differently the next time. 1  2  3  4  
I follow directions or recommended guidelines, avoid risks, and act in ways likely to keep myself and others safe. 1  2  3  4  
I consider myself to be a wise health consumer and check reliable information sources before making decisions. 1  2  3  4  
I am alert and ready to respond to life's challenges in ways that reflect thought and sound judgment. 1  2  3  4  
I have at least one hobby, learning activity, or personal growth activity that I make time for each week; something that improves me as a person. 1  2  3  4  
I actively learn all I can about products and services before making decisions. 1  2  3  4  
I manage my time well rather than let time manage me. 1  2  3  4  
My friends and family trust my judgment. 1  2  3  4  
I think about my self-talk (the things I tell myself) and then examine the evidence to see if my perceptions and feelings are sound. 1  2  3  4  
    TOTAL:     

Although each of these six dimensions of health are important, there are some factors that don't readily fit one dimension. As senior adults, you face some unique risks that others may not have. For this reason, we have added this additional section to this self-assessment that focuses on personal health promotion and disease prevention. Answer these questions and add your results to the Personal Checklist in the following section.

PERSONAL HEALTH PROMOTION/DISEASE PREVENTION
I know the warning signs of common sexually transmitted infections, such as genital warts (HPV), chlamydia, and herpes, and read new information about these diseases as a way of protecting myself. 1  2  3  4  
If I were to be sexually active, I would use protection such as latex condoms, dental dams, and other means of reducing my risk of sexually transmitted infections. 1  2  3  4  
I find ways other than binge drinking when at parties or during happy hours to loosen up and have a good time. 1  2  3  4  
When I have more than 1 or 2 drinks, I ask someone who is not drinking to drive me and my friends home. 1  2  3  4  
I have eaten too much in the last month and have forced myself to vomit to avoid gaining weight. 1  2  3  4  
I have several piercings and have found that I enjoy the rush that comes with each piercing event. 1  2  3  4  
If I were to have a tattoo or piercing, I would go to a reputable person who follows strict standards of sterilization and precautions against blood-borne disease transmission. 1  2  3  4  
I engage in extreme sports and find that I enjoy the highs that come with risking bodily harm through physical performance. 1  2  3  4  
I am careful not to mix alcohol or other drugs with prescription and over-the-counter drugs. 1  2  3  4  
I practice monthly breast/testicle self-examinations. 1  2  3  4  
    TOTAL:     

SCORING
PERSONAL CHECKLIST
Here are your scores in each of the health dimensions. Compare them to what would be considered optimal scores. Which areas do you need to work on? How does your score compare with how you rated yourself in the first part of the questionnaire?

 Ideal ScoreYour ScoreInitial Self Rating
Physical health40 Fill-out Previous Page.
Social health40 Fill-out Previous Page.
Intellectual health40 Fill-out Previous Page.
Emotional health40 Fill-out Previous Page.
Environmental health40 Fill-out Previous Page.
Spiritual health40 Fill-out Previous Page.
Personal health promotion 
and disease prevention		40 --
*If you receive a "No Answer" result in the Initial Self Rating column of this table, then selections from the previous page were not received. Please return to the previous section, mark your selections, and click "Evaluate".


What Your Scores in Each Category Mean

Scores of 35-40: Outstanding! Your answers show that you are aware of the importance of these behaviors in your overall health. More important, you are putting your knowledge to work for you by practicing good health habits that should reduce your overall risks. Although you received a very high score on this part of the test, you may want to consider areas where your scores could be improved.

Scores of 30-34: Your health practices in these areas are very good, but there is room for improvement. Look again at the items you answered that scored one or two points. What changes could you make to improve your score? Even a small change in behavior can help you achieve better health.

Scores of 20-29: Your health risks are showing! Find information about the risks you are facing and why it is important to change these behaviors. Perhaps you need help in deciding how to make the changes you desire. Assistance is available from the Aging in Place OWCS health services at your building. Consider making a change by creating and filling out the Behaviour Changes diary, you can monitor and direct your focus on your well being

Scores below 20: You may be taking unnecessary risks with your health. Perhaps you are not aware of the risks and what to do about them. Identify each risk area and make a mental note as you ponder. Whenever possible, seek additional resources, either in your building or through your local community health resources, and make a serious commitment to behaviour change. If any area is causing you to be less than functional in your personal life, seek professional help. In this site you will find the information you need to help you improve your scores and your health. Remember that these scores are only indicators, not diagnostic tools.

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