ESC Wellbeing Assessment

ESC Personal Development and Wellbeing Assessment
ESC Personal Development and Wellbeing Assessment

Being an entrepreneur creates stress with long days, little sleep and even working while sick.  This impairs cognitive functions, decision making, accuracy and increases in heart disease and other illnesses.

Our primary goal with this Assessment is to help you be the most successful that you can be and that starts with discovering where you're at today.

  • Our secondary goal is to obtain consolidated data to...
    • better serve entrepreneurs through future programs we create; and,
    • to provide statistical data to foundations and organizations to obtain grant funding to support additional entrepreneurs like you.

This Assessment will take you on a deep dive to discovering areas where we can help support you ranging from mindset and leadership to spirituality and your health.  We'll ask you questions on the 8 dimensions of wellbeing: physical, emotional, financial, spiritual, social/belonging, intellectual, occupational and environmental.

As you might have guessed, this is not a short assessment but should take no more than 10 minutes to complete.  Take note of questions that cause you discomfort as we'll ask about them at the end.

Please note: Your answers to this assessment are completely confidential and will only been seen by the You Define Wellness administrator and PathFinder. Your answers may be tabulated and shared with 3rd parties for evaluation and development purposes without identifying information.

Basic information
In order to best serve you, please answer the following questions.

Why do we ask these questions? When compiling statistical reports and analyses, the information requested provides important criteria to identify trends and will be used for tabulation purposes only. For pronouns, we want to make sure we address you in the manner you desire.

Your Name

Your Name

Clear selection

Your Email

Your Email

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What age range do you fall in?

What age range do you fall in?

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What pronouns do you identify with?

What pronouns do you identify with?

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When thinking about personal development and wellbeing services, what are your preferences as to the type and approach of coaching?

When thinking about personal development and wellbeing services, what are your preferences as to the type and approach of coaching?

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Occupational Wellbeing
As an entrepreneur, what you DO is a key factor in who you ARE.

What is your occupation

What is your occupation

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Questions about your work environment - select all that apply

Questions about your work environment - select all that apply

Strongly Agree
Agree
Disagree
Strongly Disagree
I find it necessary to hold a second job while building my business
My business leaves me fulfilled
I work on a computer all day
I stand all day
My work area is comfortable and does not create additional stress
I take regular breaks during my work day
I often eat meals at my desk
I frequently work more than 50 hours per week
Clear selection

Add any comments to elaborate on your answers in this section.

Add any comments to elaborate on your answers in this section.

Clear selection
Mindset & Leadership

Let's look at your mindset

Let's look at your mindset

Strongly Agree
Agree
Disagree
Strongly disagree
I generally have a positive attitude and outlook on life and business
I enjoy working at improving myself and my business
I adapt to change easily
Really smart people do not have to try very hard
You are who you are and you can't change that
I wait until I have all the answers before making a decision
I feel threatened by the success of others
I often get angry when I get criticism about my business
I have a clear 'Why' and am focused on it
I know my life purpose
Clear selection

Let's look at your leadership beliefs

Let's look at your leadership beliefs

Strongly Agree
Agree
Disagree
Strongly Disagree
As a leader, I can clearly state the goals others should be working towards
I break down big projects into manageable steps
When I need to provide criticism to others, I first try to understand their point of view
I consistently ask others for their input on the decision making process
Others would say I am a good communicator
I believe when you hire someone to do a job, you provide your expectations and then trust them to get the job done
People around me frequently disappoint me
I have a leadership team other than myself
Clear selection

Add any comments to elaborate on your answers in this section.

Add any comments to elaborate on your answers in this section.

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Mental Health and Relationships
Emotional wellbeing is where we find harmony and balance in our lives.

Which of the following life events have you dealt with in the past year?

Which of the following life events have you dealt with in the past year?

Clear selection

How would you rate the following?

How would you rate the following?

Strongly Agree
Agree
Disagree
Strongly Disagree
I have a good support network in my life (friends, family, caregivers)
I have a regular spiritual practice (meditation, prayer, etc)
I set aside time for myself every day (self care)
I frequently feel overwhelmed by stress, anger, and negative emotions
I often feel depressed
I am the primary caregiver for someone else
I spend too much time on social media
In the past 30 days, I have developed an abnormal loss of interest in doing daily activities & tasks
I often feel lost and all alone
Clear selection

What is your relationship status?

What is your relationship status?

Clear selection

Do you regularly participate in any groups, clubs, spiritual organizations or other activities to cultivate friendships?

Do you regularly participate in any groups, clubs, spiritual organizations or other activities to cultivate friendships?

Clear selection

Add comments here

Add comments here

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Financial Stability
Finances are one of the top stressors and will impact every other segment of your wellbeing.

Please answer the questions pertaining to Financial Wellness and elaborate in the comments section

Please answer the questions pertaining to Financial Wellness and elaborate in the comments section

Yes
No
Needs Improvement
Are you current with your rent or mortgage?
Do you have renters/homeowners, auto and life insurance?
Do you have debt other than a home?
Do you have an emergency savings fund to cover 3-6 months of expenses?
Are you saving for a major financial event in the future (i.e. house, vacation, children's college)?
Are you saving for retirement?
Do you get anxious or stressed when you think about or discuss your financial situation?
Clear selection

Comment

Comment

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Physical Health
Physical wellbeing includes both the body itself, how we move it, and what we put in to it.

Please answer these general questions about Physical Wellness

Please answer these general questions about Physical Wellness

Yes
No
Needs Improvement
Can you walk up a flight of stairs without heavy breathing or pain?
Are you dealing with chronic pain or any physical limitations?
Have you recently noticed any sudden changes in your health including reactions to certain foods?
Do you want to improve your nutrition?
Are you following a specific eating plan (i.e. Keto, gluten-free, etc)?
Do you eat out often and frequently fast food?
Are you on any prescription medications?
Do you regularly take vitamins or supplements?
Clear selection

Provide your responses to the following habits that are considered HEALTHY.

Provide your responses to the following habits that are considered HEALTHY.

Yes
No
Needs Improvement
Are you physically active on a daily basis?
Do you consistently eat healthy, nutritious foods?
Do you frequently feel bloated or have indigestion after eating?
Do you have regular (daily) bowel movements?
Do you drink water equal to half your body weight in ounces each day?
Do you feel you are receiving enough restful sleep each night?
Do you practice good daily oral hygiene?
Clear selection

Provide your responses to the following habits that are considered UNhealthy.

Remember, your answers are confidential and are critical to our ability to support you.

Provide your responses to the following habits that are considered UNhealthy.

Remember, your answers are confidential and are critical to our ability to support you.

Never Use
In Recovery or Treatment
Use on occasion
It is starting to concern me
Out of Control
Alcohol consumption
Smoking / Vaping / Dipping (tobacco / nicotine)
Marijuana (smoking, edibles)
Drugs (illegal, prescription without authorization)
Caffeine consumption
Sugar consumption
Eating disorder (bulimia, anorexia, binge eating, orthorexia, etc)
Other excessive habits (gambling, pornography, shopping, shoplifting, fitness, food)
Clear selection

To the best of your recollection, when was the last time you received the following care:

To the best of your recollection, when was the last time you received the following care:

Never
5+ years ago
3-5 years ago
1-2 years ago
Within the last year
Physical examination (including well woman/man exam)
Eye examination
Dental examination / teeth cleaning
Full blood workup and evaluation
Counseling / mental health
Clear selection

Which of the following alternative / complementary health care services do you receive at least 2x per year? Check all that apply.

Which of the following alternative / complementary health care services do you receive at least 2x per year? Check all that apply.

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Add any comments to elaborate on your answers in this section.

Add any comments to elaborate on your answers in this section.

Clear selection
Your Environment
Environmental wellbeing is about having a safe place to live and thrive.

Please answer the questions pertaining to Environmental Wellness and elaborate in the comments section

Please answer the questions pertaining to Environmental Wellness and elaborate in the comments section

Yes
No
Do not know
Are you now or have you been exposed to toxic chemicals at work, home, or hobbies?
Do you use environmentally friendly cleaning products including room deodorizers?
Do you live near farms using pesticides, high wires, power plants, or other industrial sites?
Do you now, or have you in the past, lived in a building that suffered water damage?
Has your home been tested for contaminants such as mold, asbestos, radon, lead, or illegal drug contamination?
Do you drink filtered water?
Is your home environment mostly calm, comforting and refreshing?
Is your home / office cluttered and hard to find things?
Are your neighbors loud or unfriendly?
Clear selection

Comments

Comments

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Wrap Up

You may have experienced emotions while completing some of the questions. Which question elicited the strongest emotion as a challenge you want to tackle?

You may have experienced emotions while completing some of the questions. Which question elicited the strongest emotion as a challenge you want to tackle?

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THE MAGIC WAND QUESTION...
Assume you have a magic wand and could change ONE thing about your overall wellbeing. What would you change?

THE MAGIC WAND QUESTION...
Assume you have a magic wand and could change ONE thing about your overall wellbeing. What would you change?

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Now that you have taken the assessment, prioritize for us the areas you want to work on (this is not a ranking; you may use a category more than once).

Now that you have taken the assessment, prioritize for us the areas you want to work on (this is not a ranking; you may use a category more than once).

Not a priority
Low priority
Medium priority
Highest priority
Physical health (includes fitness, nutrition, general physical health)
Mental health (includes stress & anxiety)
Relationships and communication
Financial health (includes personal budgeting)
Mindset / Success
Occupational (includes leadership & team building)
Other
Clear selection

What do you hope to get out of participating in the Personal Development and Wellbeing program? Where do you hope to see improvement at the end of this program?

What do you hope to get out of participating in the Personal Development and Wellbeing program? Where do you hope to see improvement at the end of this program?

Clear selection

ESC Wellbeing Assessment February 27, 2022
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