Wellbeing check-in questionnaire
A 12-item non-clinical check-in on energy, sleep routine and social connection, written for coaching conversations.
"Use this template" opens the Psych Lab builder with this brief pre-filled — you review and edit every item before it goes out.
Response scale
1–5 agreement scale, scored as a mean per subscale.
- 1Strongly disagree
- 2Disagree
- 3Neither
- 4Agree
- 5Strongly agree
Items (12)
Items marked reverse are flipped before scoring with new = (max + min) − raw.
| # | Item | Subscale | Scoring |
|---|---|---|---|
| 1 | I have felt physically up to my usual activities. | Energy | Direct |
| 2 | I have felt worn out by mid-afternoon. | Energy | Reverse |
| 3 | I have been able to focus on one thing at a time. | Energy | Direct |
| 4 | Small tasks have felt heavier than usual. | Energy | Reverse |
| 5 | I have kept a fairly regular sleep schedule. | Routine | Direct |
| 6 | My eating pattern has been irregular. | Routine | Reverse |
| 7 | I have moved my body most days. | Routine | Direct |
| 8 | I have taken proper breaks away from screens. | Routine | Direct |
| 9 | I have spent time with people I enjoy. | Connection | Direct |
| 10 | I have kept to myself more than I would like. | Connection | Reverse |
| 11 | There is someone I could talk to about something difficult. | Connection | Direct |
| 12 | I have felt part of a group that matters to me. | Connection | Direct |
Score ranges
Low
1.0 – 2.4This area has been hard lately. It is a conversation starter, not a finding — encourage professional support where appropriate.
Mixed
2.5 – 3.7Some days work and others do not. Look at which specific items sit lowest.
Steady
3.8 – 5.0This area has been holding up well over the period asked about.
How to score and run it
- This is a self-report check-in for reflection and coaching. It is not a clinical or diagnostic instrument.
- Anchor the wording to a period ("over the past two weeks") so repeat scores are comparable.
- Report subscales separately; a single wellbeing number hides which area needs attention.
This is a self-report questionnaire template for feedback and reflection. It is not a clinical or diagnostic instrument, and scores should not be used to make decisions about an individual on their own.
Run this with automatic scoring
Psych Lab handles the reverse scoring, subscale bands, join codes and CSV export for you — and you can list the finished questionnaire publicly.