1.How would you rate your overall health?

excellent

good

poor

2.How many times per week you engage in 30 minutes of  physical activates?

0

1

2

3

4

5 or more

Never

3.How often do you eat at a restaurant?

Everyday

once per week

more than twice a week

never

4.How many cups of fruits you eat per day?

0

one

more than five per week

5.When is the last time you saw a doctor?

last six months

more than two years ago

can remember

6.When is the last time you saw a dentist?

last 6 months 

Over a year

more than two years

7.During the past 4 weeks, did experience or felt bothered by any emotional problems such as feeling anxious, depressed, irritable, or sad?

Extremely bothered

bothered

somewhat bothered

not bothered

8.During the past 4 weeks, did you feel supported when you wanted or needed help from others? For example, if you felt lonely and wanted to talk to someone or got sick.

Extremely supported

somewhat supported

not supported

9.Do you believe maintaining your physical and emotional wellbeing can make a difference in your overall wellness?

Yes

No

10.Do you believe having a community group promoting wellness can make a difference in our young people perception on their life?

Yes

No