CHANGE workshop health and wellbeing scorecard Workshop name & venue * Name * First Name Last Name Email * Date * MM DD YYYY Present cirumstances I am happy with my current circumstances in life as they are today Strongly Disagree Disagree Neutral Agree Strongly Agree I don’t have the belief that I can make changes to my present circumstances Strongly Disagree Disagree Neutral Agree Strongly Agree I have accepted my life’s current circumstances as they are today Strongly Disagree Disagree Neutral Agree Strongly Agree I don’t have the ability to change my circumstances as they are today Strongly Disagree Disagree Neutral Agree Strongly Agree I want to change my current circumstances but don’t know how to do it Strongly Disagree Disagree Neutral Agree Strongly Agree Your wellbeing I have a good understanding of what overall wellbeing means to me Strongly Disagree Disagree Neutral Agree Strongly Agree I know what is meant by physical, mental, spiritual & emotional wellbeing Strongly Disagree Disagree Neutral Agree Strongly Agree I priortise and make time to improve all aspects of my wellbeing Strongly Disagree Disagree Neutral Agree Strongly Agree I only focus on improving certain aspects of my wellbeing Strongly Disagree Disagree Neutral Agree Strongly Agree I have a balanced approach to improving my overall wellbeing Strongly Disagree Disagree Neutral Agree Strongly Agree Sense of self I have a healthy relationship with who I am as person Strongly Disagree Disagree Neutral Agree Strongly Agree I have a healthy relationship with my self-image Strongly Disagree Disagree Neutral Agree Strongly Agree I have a healthy relationship with my sense of self- worth/value Strongly Disagree Disagree Neutral Agree Strongly Agree I am the most important person in my own life Strongly Disagree Disagree Neutral Agree Strongly Agree The most important relationship that I have is the one with myself Strongly Disagree Disagree Neutral Agree Strongly Agree Your future I live in fear and worry about my future Strongly Disagree Disagree Neutral Agree Strongly Agree I feel optimistic about my future Strongly Disagree Disagree Neutral Agree Strongly Agree I don’t think about my future Strongly Disagree Disagree Neutral Agree Strongly Agree I have goals for my future Strongly Disagree Disagree Neutral Agree Strongly Agree I have an idea of the person I want to be in the future Strongly Disagree Disagree Neutral Agree Strongly Agree Please write a few words about your biggest challenges, struggles, barriers you are facing in your life right now: * Please write a few words about what aspects of your life you would love to change if you could change them: * Finish this statement: In 6 months’ time I will be: * Thanks for filling out our questionnaire!
