Robust Life Questionnaire

Choose One Female Male

How many servings of fresh vegetables do you eat daily?

Choose One 0-1 2-3 4-5 6-8 10+

How many servings of fresh fruit do you eat daily?

Choose One 0 1 2 3 4+

How often do you eat processed foods each day?

Choose One 0 1 2 3 4+

How much time do you engage in stretching each week?

Choose One 0-1 hr 1-2 hrs 2-3 hrs 3-4 hrs 4-5 hrs 5+ hrs

How often do you work with weights or resistance training each week?

Choose One 0-1 hr 1-2 hrs 2-3 hrs 3-4 hrs 4-5 hrs 5+ hrs

How much time do you spend doing aerobic exercise?

Choose One 0-1 hr 1-2 hrs 2-3 hrs 3-4 hrs 4-5 hrs 5+ hrs

How much water a day do you drink?

Choose One 0-8 oz 8-16 oz 48 oz 64 oz 96 oz +

Overweight?

Yes No

Smoke?

Yes No

Drink more than 3 servings of alcohol per week?

Yes No

Live with High Stress?

Yes No

Relationship Problems?

Yes No

Personal History of Serious Illness?

Yes No

Family History of Serious Illness?

Yes No

How much sleep do you average each night?

Choose One <5 6-8 hrs 8-9hrs 9+

Is it difficult to fall asleep?

Yes No

Are you often sleepy during the day?

Yes No

Are you rested when you wake up?

Yes No

Level of stress at work?

Choose One Low Medium High

Level of stress at home?

Choose One Low Medium High

Amount of time spent in quiet solitude weekly?

Choose One 0 hrs 1 hr 1-2 hrs 2-3 hrs 3-4 hrs 4-5 hrs 5+ hrs

How many close relationships do you have with others?

Choose One 0 1 2 3 4 5+

How often do you experience negative emotions such as fear, anxiety, depression, anger, worry, confusion, lack of direction, overwhelm, helplessness or hopelessness?

Choose One rarely occasionally often

How many hours do you work each week?

Choose One 0-20 20-30 30-40 40-50 50-60 60+

How much time do you spend recreating each week?

Choose One 0-5 5-10 10+

How many times do you take off at least 7 days in a row each year?

Choose One never once twice three times four+ weeks

How content are you with your work?

Choose One not at all somewhat very love it

How much time do you spend watching TV or news each week?

Choose One never 2 hrs or less 4 hrs 8 hrs 10+ ea/week

Are you living intentionally with passion, purpose and peace?

Yes No

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