Bio-Psycho-Social Health Index

Code Name: _________________________________    Date: ____________

 

 Part i - Please indicate your answer with the number for each of the following:

           5                                  4                                 3                      2                                  1

     Always                      Mostly                Sometimes             Not Often                  Never   

 1. _____ I exercise regularly (2 times a week or more)

 2. _____  I eat meals at regular times each day.

 3. _____  I  have plenty of energy to go about my daily tasks.

 4. _____  I suffer from bad headaches.

 5. _____  I suffer from pains in my body.

 6. _____  I socialise with people if given the opportunity.

 7. _____  I feel shy when meeting new people.

 8. _____  I  feel excluded from social activities.

 9. _____  I feel alone.

10. _____ I  have pains in the heart or chest.

11. _____ I feel happy with the way my life is.

12. _____ I discuss this feeling with someone close to me.

13. _____ I usually belch a lot after eating.

14. _____ I  go out with friends on a regular basis to the cinema.

15. _____                                                                            to nightclubs or bars.

16. _____                                                                            to religious meetings.

17. _____                                                                            to other gatherings.

        e.g., ______________

18. _____  I participate in team sports or activities on a regular basis.

19. _____  I get colds/flu on a regular basis.

20. _____  I prefer my own company.

21. _____  I often have spells of severe dizziness.

22. _____  I wear myself out worrying about my health.

23. _____  I  wish I always had someone at my side to advise me.

24. ______I generally keep a low profile due to fear.

25. _____  I often wish I were dead and away from it all.

27. ______My muscles and joints constantly feel stiff.
28. ______I  usually feel tired and exhausted in the morning.
29. ______I am extremely shy or sensitive.
30. ______I often shake or tremble..

31. ______I feel uncomfortable to adjust to new foods.

32. ______I feel sad living in unfamiliar surroundings.

33. ______I fear for my personal safety because of my different cultural background.

34. ______I feel intimidated to participate in social activities.
35. ______Others are biased toward me.

36. ______Others don't appreciate my cultural values.

37. ______I often break out in a cold sweat.

38. ______People often annoy or irritate me.

39. ______I usually feel unhappy and depressed

40. ______I feel insecure.

41. ______I  feel a sense of belonging here (to a community)

42. ______It makes me angry to have anyone tell me what to do.

43. ______People insult me verbally.

44. _____ I  usually have great difficulty in falling asleep or staying sleep.

45. _____  Worrying continually gets me down.

Part ii  -  Also please complete the following questions:

A) Indicate on a scale of 1 - 10 the degree of stress you are currently experiencing, where 1=no stress at all and 10 is extreme stress at your limits___________________.

    B) Specify significant stressors you are currently experiencing:

    C) Indicate the approximate hours of T'ai Chi, Yoga, Meditation, Team or Individual Sports,  

or other such practices _______________  you have been averaging over each of the past four weeks.

    D) Indicate any other means of coping you have been enlisting in recent days or weeks: