Vitality Survey

Please score each item based on the scale below.

Scale

0 = Never
1 = Seldom
2 = Occasionally
3 = Often
4 = Very Often

General Information
Name
How Often Do You...
1. Experience indifference (don't care)?
2. Lose your sense of humor / take life too seriously?
3. Experience doubt or indecision?
4. Experience worry or anxiety?
5. Feel over cautious or pessimistic?
6. Lack self confidence or have low self esteem?
7. Experience stress or feel nervous or tense?
8. Feel irritable or oversensitive?
9. Experience difficulty concentrating and loss of clear thought?
10. Experience inadequate energy (fatigue)?
11. Have coffee, tea, tobacco, sugar, or other stimulants as a pick up?
12. Experience nervous indigestion?
13. Experience loss of sex drive?
14. Experience difficulty sleeping?
15. Experience difficulty getting up in the morning?
16. Feel run down?
17. Feel depressed?
18. Feel like crying for no reason?
19. Find it difficult to sit quietly (without fidgeting, talking, reading, watching TV, etc.)?
20. Find it difficult to express your feelings?
21. Experience rapid heart beat or panic?
22. Feel moody?
23. Feel suicidal or wonder whether life is worth living?
24. Have anxiety about not having enough money?
25. Fear ill health?
26. Fear criticism?
27. Fear loss of love?
28. Fear old age or death?
29. Feel "something is the matter with me" but don't know what?
30. Think you might be going crazy (losing it)?
Grand Total

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