Complete your annual wellness assessment
Please select "Yes" or "No" for each question.
1. Have you felt you ought to cut down on your drinking or drug use?
2. Have people annoyed you by criticizing your drinking or drug use?
3. Have you felt bad or guilty about your drinking or drug use?
4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?
CAGE-AID Score: 0/4 (Score ≥2 suggests possible substance use disorder)
Can you perform these activities?
1. Can you take care of yourself (eating, dressing, bathing, using the toilet)?
2. Can you walk indoors on flat ground?
3. Can you climb a flight of stairs or walk uphill?
4. Can you walk a block at your own pace?
5. Can you do light work around the house (dusting, washing dishes)?
6. Can you do moderate work around the house (vacuuming, light yard work)?
7. Can you do heavy work around the house (scrubbing floors, moving heavy furniture)?
8. Can you do light recreational activities (bowling, golf)?
9. Can you do moderate recreational activities (doubles tennis, dancing)?
10. Can you do strenuous sports (singles tennis, basketball)?
Estimated Peak VO2: 10.2 mL/kg/min
How likely are you to doze off in the following situations? Rate your chances from 0 (no chance) to 3 (high chance).
1. Sitting and reading
2. Watching TV
3. Sitting inactive in a public place (e.g., a theater or a meeting)
4. As a passenger in a car for an hour without a break
5. Lying down to rest in the afternoon when circumstances permit
6. Sitting and talking to someone
7. Sitting quietly after a lunch without alcohol
8. In a car, while stopped for a few minutes in traffic
Total Score: 0/24
It is unlikely that you are abnormally sleepy.
How much have you been bothered by the following symptoms during the past month? Rate from 0 (Not at All) to 3 (Severely).
1. Numbness or tingling
2. Feeling hot
3. Wobbliness in legs
4. Unable to relax
5. Fear of worst happening
6. Dizzy or lightheaded
7. Heart pounding or racing
8. Unsteady
9. Terrified or afraid
10. Nervous
11. Feeling of choking
12. Hands trembling
13. Shaky or unsteady
14. Fear of losing control
15. Difficulty in breathing
16. Scared
17. Indigestion
18. Faint or lightheaded
19. Face flushed
20. Hot or cold sweats
Total Score: 0/60
Very low anxiety. Unlikely that you are experiencing significant anxiety symptoms.
Please answer the following questions about your safety and well-being.
1. Do you feel safe in your relationship?
2. Have you ever been in a relationship where you were threatened, hurt or afraid?
3. Are your friends or family aware that you have been hurt? Could you tell them, and they would be able to give you support?
4. Do you have a safe place to go and the resources you need in an emergency?
Over the last 2 weeks, how often have you been bothered by any of the following problems?
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead or of hurting yourself in some way
Total Score: 0/27