PLEASE ANSWER EACH THE FOLLOWING GENERAL FUNCTIONING QUESTION ACCORDING TO THE WAY YOU FELT IN THE LAST 4-6 WEEKS, EXCEPT WERE INDICATED DIFFERENTLY.
There are no right or wrong answers. Your first answer is usually the best one. “Gut-feeling” answers are more valuable in answering this questionnaire than well thought-through answers.
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1. Are you able to meet your basic financial commitments?
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2. Do you have a monthly budget?
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3. Do you have enough self-discipline to stay within your budget?
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4. Do you make financial decisions with your personal image or current trends in mind, rather than with your budget available?
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5. Do you currently spend more on your house (bond or rent) than on a car?
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6. Are you able to save?
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7. Do you worry about your current monthly financial commitments?
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8. Are you only providing financially for yourself and your direct family, e.g., own children (not contributing to parents or extended family)?
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9. Do you have a medical aid or medical saving plan?
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10. Do you end up in debt because you help others?
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11. Do you provide for your old age? E.g., do you contribute to a pension fund or retirement scheme?
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12. Do you feel financially secure?
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13. Do you currently pay more than 70% of your income back to debt (loans, accounts, monthly instalments, etc.)?
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14. Do you firmly believe that there is a higher source/God that will provide in all your needs, no matter what the circumstances?
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Your Finance Section Score
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Your Finance Section Points
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15. Do you have a close friend in whom you can confide?
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16. Outside your family, do you feel there are people who really care about YOU?
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17. Do you have enough energy, time and opportunities to balance your personal, work, family and social needs in a responsible way?
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18. Do you have a close friend or family member that struggles with addiction, aggressive behaviour and/or emotional problems?
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19. Are your friends supporting you to live a healthy and responsible lifestyle?
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Your Friend & Social Life Section Score
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Your Friends & Social Life Section Points
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20. As a child, did you feel that there were people in your life who really cared about you?
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21. Overall, do you think your childhood was a good preparation for adult life?
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22. Were there any premature or unnatural deaths in your family or extended family?
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23. Were there any miscarriages or abortions in your family or extended family?
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24. Were there any children adopted in your own or extended family?
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25. Did you grow up with your biological father and was he emotionally and physically available during your upbringing?
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26. Did you grow up with your biological mother and was she emotionally and physically available during your upbringing?
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27. Were both your parents excited about expecting you?
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28. Do you feel that your family suffers from bad luck?
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Your Family Section Score
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Your Family Section Points
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29. Have you taken the COVID vaccine?
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30. Do you spend time on activities of your own preference – just because you like it?
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31. Do you know your HIV status?
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32. Do you go for general medical tests or assessments and dental check-ups at least once in 24 months?
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33. Do you currently have a chronic medication prescription?
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34. Do you incorporate cardiovascular exercise (e.g. walking, jogging, swimming, cardio circuit, etc.), at least 3 times per week for 30 minutes per session?
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35. Do you eat a minimum of 2 healthy meals per day? (Including a minimum of 4 cups of raw veggies, 2-3 fresh fruits, high fibre & fish.)
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36. Do you use some of the following supplements on a regular basis or as needed? Omega 3, Vit B, Vit C, Vit D, magnesium
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37. Do you drink 250 ml water per 10 kg body mass per day? Plus 250 ml extra per each cup of coffee or alcoholic you drink?
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38. Do you laugh out loud every day?
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39. Do you believe in prevention rather than cure?
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40. Do you prefer natural remedies and supplements rather than the typical prescription medication?
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41. Do you get 7-8 hours continuous sleep on average during a 24-hour-period?
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42. Do you know what your ideal weight is – according to the Body Mass Index scale (BMI) or a medical practitioner, dietician, or bio kineticist?
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43. Do you believe that you have a purpose here on earth?
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44. Do you try to live a life of gratitude?
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45. Do you believe in a God/Higher Power that is loving?
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46. Do you feel you are contented with your life (more than 70% of the time)?
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Your Personal Health Section Score
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Your Personal Health Section Points
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If Married or in a Committed Relationship
47. Are you interested in your partner’s hobbies or activities?
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48. Do you both enjoy spending time together?
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49. Do you feel that your partner understands and supports you?
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50. Do you feel that you understand your partner?
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51. Do you experience love, trust, and respect in your partnership?
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52. Do you experience self-confidence when spending time with your partner and direct family?
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53. Are you really satisfied with your partnership?
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54. Do you feel that your partner really cares about you?
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55. Do you have a fulfilled emotional and intimate relationship with your partner?
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Your Marriage/Relationship Section Score
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Married Section Points
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56. Overall, do you feel fulfilled in your single life?
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57. Do you feel understood and supported by family or friends?
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58. Do you truly “belong to” or “feel part of” a formal or informal social group outside the workplace?
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59. Do you prefer to be single?
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60. Do you feel comfortable meeting other single people?
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61. Do you have regular contact with other single people?
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62. Are your need for companionship satisfied?
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63. Do you experience self-confidence when socialising?
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64. Do you deal with your sexual needs in a safe and responsible way?
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Your Single Section Score
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Your Single Section Points
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Only parents still taking care of children
65. Do you currently feel you have enough financial and emotional resources to take care of your child/children?
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66. Do you have ANY support with the upbringing of your children? Do you have people who share in the financial and daily responsibilities?
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67. Do you enjoy bringing up your children?
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68. Do you have enough free time for yourself?
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69. Do you feel that you understand your children?
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70. Do you feel confident in disciplining and guiding your children?
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71. Do you have mutual respect in the relationship with your children?
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72. Do you spend at least 3 hours per month on fun activities of your children’s choice?
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73. Do your children discuss their relationship issues and other frustrations in life with you?
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74. Do you struggle to say no to your children?
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75. Do you stretch your children’s potential?
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76. Do you teach your children to be independent from an early age?
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77. Do you feel the need to take care of children who are supposed to be independent?
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78. Do you allow your children to make mistakes and learn from the consequences without scolding them for it?
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Your Caretaking Section Score
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Your Caretaking Section Points
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79. Do you feel overworked or too tired to work?
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80. Do you feel too tired to enjoy life?
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81. Do you frequently have headaches?
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82. Do you suffer from aches and pains?
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83. Is sex an unwelcome activity in your life?
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84. Are you worried about your physical or emotional health?
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85. Do you struggle to control your medical symptoms?
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86. Do you struggle to forgive (others and/or yourself)?
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87. Do you fear death (your own or a loved one’s)?
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88. Do you struggle to deal with the death of anyone you felt close to, who died more than 2 years ago?
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Your Health Section Score
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Your Health Section Points
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89. Do you often feel disappointed by people you trust?
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90. Do you often find that people are hurtful to you?
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91. Do you feel that people or circumstances are often against you?
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92. Are you very upset when life is unfair?
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93. Would you like to have more power and influence?
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94. Are you unhappy with some aspects of yourself, e.g. do you think you should be prettier, thinner, taller, smarter, more assertive, more achieving or productive, etc.
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95. Does it upset you tremendously if undesirable things happen to yourself or others?
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96. Are there certain things you hate doing, but you still do them because you feel you are forced to?
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97. Do you struggle to acknowledge and negotiate your own needs?
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98. Do you find it difficult to say “NO” to people, even if they have unrealistic demands?
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Your Influence Section Score
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Your Influence Section Points
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99. Are you sometimes very depressed?
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100. Do you often feel vaguely insecure?
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101. Do you feel unduly guilty at times?
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102. Do you sometimes wish you were dead?
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103. Do you find that people are often unappreciative of your efforts?
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Your Moods Section Score
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Your Moods Section Points
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104. Do you experience discomfort or ineffectiveness in the workplace because of high stress levels?
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105. Did you experience some of the following symptoms during the last 3 months? Indigestion/constipation/diarrhoea/heart palpitations/lack of concentration/grinding of teeth/painful jaw/muscle tension.
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106. During the last 2 years: Do you have a family member or someone close to you with undesirable behaviour that is difficult to manage, e.g., extreme anger or emotional outbursts/depression/dependency or other negative tendencies?
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107. During the last 2 years: Did you experience the death of a loved one / serious relationship troubles / change of personal or relationship status?
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108. During the last 2 years: Did you experience a difficult teenager at home / small children at home / problems with in-laws/change in family size?
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109. During the last 2 years: Did you experience a change of work/work responsibilities/work hours/work status?
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110. During the last 2 years: Did you experience serious health issues (accident or illness)?
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111. During the last 2 years: Did you experience a change in living conditions/residence/social activities/friendships/religious activities?
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112. Do you experience sleeping problems? / Do you struggle to get a good night’s rest on a regular basis (7-8 hours)?
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113. Are there traumatic events in your life that you still think about regularly, or that you are aware that you have not dealt with completely?
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114. Did you experience regular anger outbursts, or did you actively suppress anger during the last 3 months?
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115. Do you experience flashbacks or intrusive thoughts of traumatic events of the past?
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116. Did you experience intense physical reactions (over-reactions), oversensitivity (hyper alertness) or avoidance in your day-to-day activities during the last 3 months, possibly related to previous traumatic events in your life?
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117. Do you have disturbing dreams or nightmares?
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118. Did you experience any anxiety/fears without a rational reason during the last 3 months?
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Your Stress & Trauma Section Score
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Your Stress & Trauma Section Points
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