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1.
I eat at least one hot, balanced meal a day.
1 (always)
2
3 (sometimes)
4
5 (never)
2. I
get 7 to 8 hours of sleep at least four nights a
week.
1 (always)
2
3 (sometimes)
4
5 (never)
3. I
give and receive affection regularly.
1 (always)
2
3 (sometimes)
4
5 (never)
4. I
have at least one relative within 50 miles on
whom I can rely.
1 (always)
2
3 (sometimes)
4
5 (never)
5. I
exercise to the point of perspiration at least
twice a week.
1 (always)
2
3 (sometimes)
4
5 (never)
6. I
limit myself to less than half a pack of
cigarettes a day.
1 (always)
2
3 (sometimes)
4
5 (never)
7. I
drink fewer than five alcoholic drinks a week.
1 (always)
2
3 (sometimes)
4
5 (never)
8. I
am the appropriate weight for my height.
1 (always)
2
3 (sometimes)
4
5 (never)
9. I
have an income adequate to meet basic expenses.
1 (always)
2
3 (sometimes)
4
5 (never)
10.
I get strength from my religious or spiritual
beliefs.
1 (always)
2
3 (sometimes)
4
5 (never)
11.
I regularly attend club or social activities.
1 (always)
2
3 (sometimes)
4
5 (never)
12.
I have a network of friends and acquaintances.
1 (always)
2
3 (sometimes)
4
5 (never)
13.
I have one or more friends to confide in about
personal matters.
1 (always)
2
3 (sometimes)
4
5 (never)
14.
I am in good health (including eyesight,
hearing, and teeth).
1 (always)
2
3 (sometimes)
4
5 (never)
15.
I am able to speak openly about my feelings when
angry or worried.
1 (always)
2
3 (sometimes)
4
5 (never)
16.
I have regular conversations with the people I
live with about domestic problems – for example,
chores or money.
1 (always)
2
3 (sometimes)
4
5 (never)
17.
I do something for fun at least once a week.
1 (always)
2
3 (sometimes)
4
5 (never)
18.
I am able to organize my time effectively.
1 (always)
2
3 (sometimes)
4
5 (never)
19.
I drink fewer than three cups of coffee (or
other caffeine-rich drinks) a day.
1 (always)
2
3 (sometimes)
4
5 (never)
20.
I take some quiet time for myself during the
day.
1 (always)
2
3 (sometimes)
4
5 (never)
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