* An asterisk indicates a required field.
How satisfied are you with your work/career?
Very satisfied
Mostly satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
How satisfied are you with where and how you live (lifestyle)?
Very satisfied
Mostly satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
How satisfied are you with your financial resources?
Very satisfied
Mostly satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
How satisfied are you with the amount and quality of fun and relaxation in your life?
Very satisfied
Mostly satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
How satisfied are you with your spirituality?
Very satisfied
Mostly satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
How satisfied are you with your community involvement?
Very satisfied
Mostly satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
How satisfied are you with your sense of freedom, flexibility, and opportunities?
Very satisfied
Mostly satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
How satisfied are you with your relationship with your spouse or partner (as you desire this primary relationship to be)?
Very satisfied
Mostly satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
How satisfied are you with your relationships with your family?
Very satisfied
Mostly satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
How satisfied are you with your relationships with your friends?
Very satisfied
Mostly satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
How satisfied are you with your relationships with your business associates or co-workers?
Very satisfied
Mostly satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
I would like to lose weight
Yes
No
I would like to be in better shape
Yes
No
I would like more time to do activities that I think are fun
Yes
No
I would like to have more energy
Yes
No
I would like to have more peace
Yes
No
I (always, usually, sometimes, rarely, never) feel great physically
Always
Usually
Sometimes
Rarely
Never
I (always, usually, sometimes, rarely, never) know how I am feeling, emotionally
Always
Usually
Sometimes
Rarely
Never
How often do you feel you are putting on a mask or playing a role? This is as you define it: anytime you feel that you are not really being “yourself”. Some examples may be: “being a professional”, “acting my age”, dressing in ways you would not choose to dress, etc.
Always
Usually
Sometimes
Rarely
Never
I think of aging as:
Fight it any way possible
Necessary evil
Part of life
Only a number for the years I have lived
Is your work your passion?
Yes
Sometimes
No
Do you own your own business?
Yes
No
Are you employed by someone else?
Yes
No
* What would you like more of in your life?
* What would you like less of (or to eliminate) in your life?
What is your age?
Under 20 years
21 to 30 years
31 to 40 years
41 to 50 years
51 to 60 years
61 to 70 years
71 to 80 years
Over 80 years
What is your gender?
Male
Female
Are there any other comments you would like to share regarding loving your life?
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Anonymous
Your first name
Your first and last names
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Yes
No
* Email Address
* First Name
Last Name