| I eat at least one hot, balanced meal each day |
| Always - 1 2 3 4 5 - Never |
| I get seven to eight hours of sleep at least four nights a week |
| Always - 1 2 3 4 5 - Never |
| I have at least one relative within 50 miles on whom I can rely |
| Always - 1 2 3 4 5 - Never |
| I exercise to the point of perspiration at least twice each week |
| Always - 1 2 3 4 5 - Never |
| I avoid smoking or other tobacco products |
| Always - 1 2 3 4 5 - Never |
| I drink fewer than five alcoholic drinks per week |
| Always - 1 2 3 4 5 - Never |
| I am the appropriate weight for my height |
| Always - 1 2 3 4 5 - Never |
| I have income which is adequate to meet my basic needs |
| Always - 1 2 3 4 5 - Never |
| I get strength from my spiritual or religious beliefs |
| Always - 1 2 3 4 5 - Never |
| I regularly attend club or social activities |
| Always - 1 2 3 4 5 - Never |
| I have a network of friends and acquaintances |
| Always - 1 2 3 4 5 - Never |
| I have one or more friends to confide in about personal matters |
| Always - 1 2 3 4 5 - Never |
| I am in good health (including eyesight, hearing and teeth) |
| Always - 1 2 3 4 5 - Never |
| I am able to speak openly about my feelings when I am angry or worried |
| Always - 1 2 3 4 5 - Never |
| I have regular conversations with people I live with about domestic problems (for example, chores or money) |
| Always - 1 2 3 4 5 - Never |
| I am able to organize my time effectively |
| Always - 1 2 3 4 5 - Never |
| I drink fewer than three cups of coffee or other caffeinated beverages daily |
| Always - 1 2 3 4 5 - Never |
| I take some quiet time for my self every day |
| Always - 1 2 3 4 5 - Never |
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