Self Assessment Tool
Oyler’s "Controllables" Self Assessment
All Scoring on questions = 1- 5 points. Strongly Disagree = 1pt; Strongly Agree = 5 pt.
Each set of questions (questions 1 and 2; questions 3 and 4; etc. comprise a domain).
Exercise
- 1. I engage in some form of heart/cardio activity or exercise for at least 30 minutes at least twice a week. Note: this can include activities such as gardening/landscaping , swimming, or walking along with the traditional “cardio” exercises.
____ Strongly disagree = 1 pt
____ Disagree somewhat
____ Neither agree or disagree
____ Agree somewhat
____ Strongly agree = 5 pt
- 2. I engage in some form of strengthening activity or exercise for at least 30 minutes at least twice a week. Note: this can include activities such as squats, pushups or pullups, along with traditional strength training such as kettlebells or weightlifting.
____ Strongly disagree
____ Disagree somewhat
____ Neither agree or disagree
____ Agree somewhat
____ Strongly agree
Dietary
- 3. I have knowledge regarding my best practice dietary habits that I have learned from my doctor, or other sources.
____ Strongly disagree
____ Disagree somewhat
____ Neither agree or disagree
____ Agree somewhat
____ Strongly agree
- 4. I generally engage in best dietary practices as evidenced by: my bmi/weight , or my doctors feedback, or other factors tests. Those factors may include glucose levels, lipid panels re cholesterol, etc.
____ Strongly disagree
____ Disagree somewhat
____ Neither agree or disagree
____ Agree somewhat
____ Strongly agree
Environment
- 5. I reside in a safe environment that is likely to meet my physical, social, and spiritual needs for the foreseeable year 12 months and/or I have a methodology to ensure my environment can meet my likely future safety needs.
____ Strongly disagree
____ Disagree somewhat
____ Neither agree or disagree
____ Agree somewhat
____ Strongly agree
- 6. I have family, friends , or neighbors that I can socialize with and would be available in case of an emergency.
____ Strongly disagree
____ Disagree somewhat
____ Neither agree or disagree
____ Agree somewhat
____ Strongly agree
Engagement in activities
- 7. I engage in activities on a weekly basis that are pleasurable or fun and I engage in those activities with others that I care for and/or who care for me.
____ Strongly disagree
____ Disagree somewhat
____ Neither agree or disagree
____ Agree somewhat
____ Strongly agree
- 8. I engage in activities on a weekly basis that are meaningful or give a sense of achievement with others that I care for and/or who care for me. This can include volunteering, attending classes, etc.
____ Strongly disagree
____ Disagree somewhat
____ Neither agree or disagree
____ Agree somewhat
____ Strongly agree
Future Planning
- 9. I have engaged in planning for my living including:
Where I will reside.
Who can assist with my care. (Paid and unpaid persons).
Understanding likely expenses of my needs.
____ Strongly disagree
____ Disagree somewhat
____ Neither agree or disagree
____ Agree somewhat
____ Strongly agree
- 10. I have planned for significant illness/my passing by:
Completing advance directives
Identifying a medical power of attorney
Identifying a durable power of attorney
Completing a last will.
Completing arrangements or identifying who will.
____ Strongly disagree
____ Disagree somewhat
____ Neither agree or disagree
____ Agree somewhat
____ Strongly agree
Education
- 11. On a weekly basis, I continue to learn in one or more of the following domains:
Spiritual or religious.
Health and wellness.
Traditional and/or non-traditional education.
Other.
____ Strongly disagree
____ Disagree somewhat
____ Neither agree or disagree
____ Agree somewhat
____ Strongly agree
- 12. Generativity = “Others benefit from my experience, knowledge.”.
I pass my knowledge on to others in one or more of the following domains:
Spiritual or religious.
Health and wellness.
Traditional and/or non-traditional education.
Other.
____ Strongly disagree
____ Disagree somewhat
____ Neither agree or disagree
____ Agree somewhat
____ Strongly agree
Adaptation
- 13. Regarding adapting the aging process, I address the “controllable” aspects of aging through goal directed thoughts and behaviors. This can include my health/wellness regime, home modifications, adaptive socialization, etc.
____ Strongly disagree
____ Disagree somewhat
____ Neither agree or disagree
____ Agree somewhat
____ Strongly agree
- 14. Regarding adapting to the aging process,I have formal and informal supports to assist with the “uncontrollable” such as medical concerns, adapting my living area, assisting with my activities of daily living, etc.
____ Strongly disagree
____ Disagree somewhat
____ Neither agree or disagree
____ Agree somewhat
____ Strongly agree
Meaning
- 15. I have identified life domains that have meaning to me and I engage in cognitions and/or behaviors that are meaningful in those domains on a weekly basis.
____ Strongly disagree
____ Disagree somewhat
____ Neither agree or disagree
____ Agree somewhat
____ Strongly agree
- 16. I am leaving a legacy to other persons, institutions, or causes that are meaningful to me. This legacy can be an emotional legacy, a financial legacy, etc. Examples include: “My children love and respect nature and I have contributed to that.”, “My contribution of time and treasure to the pet shelter is meaningful to me.”, “My will contains…”
____ Strongly disagree
____ Disagree somewhat
____ Neither agree or disagree
____ Agree somewhat
____ Strongly agree
Spiritual beliefs about problems
- 17. God, or the universe, is a partner in my problem solving methodologies. This can mean: I bring my problems to God, I believe that God cares about my problems, I believe God has the ability to assist with my problems.
____ Strongly disagree
____ Disagree somewhat
____ Neither agree or disagree
____ Agree somewhat
____ Strongly agree
- 18. Looking back, and looking forward, I believe that: Though age-related challenges/problems can bring many hardships I can also factually say, “Problems are one method of producing spiritual growth.”
____ Strongly disagree
____ Disagree somewhat
____ Neither agree or disagree
____ Agree somewhat
____ Strongly agree
Emotional Health
- 19. I have a mental health knowledge and “tools” (KSA’s) to assist with age-related emotional challenges such as sadness, loneliness, grief, or anxiety when encountering challenges such as loss of others I care for, medical decline, less than desirable living options etc..
____ Strongly disagree
____ Disagree somewhat
____ Neither agree or disagree
____ Agree somewhat
____ Strongly agree
- 20. I have formal and/or informal supports to assist with those age-related emotional challenges.
____ Strongly disagree
____ Disagree somewhat
____ Neither agree or disagree
____ Agree somewhat
____ Strongly agree
RESULTS, SCORING, USE OF DATA
- Results are utilized to explore methods of increasing well-being.
- 100 possible points.
- Total score under 80 will benefit from deeper exploration.
- Each question with a score of 3 or less will benefit from being explored/addressed.
- Each domain (each set of 2 questions) with a combined score of 6 or less will benefit from being explored/addressed.
- Domains can be addressed through cognitive and/or behavioral adaptations.
Total Score _______________
Questions with a score of 3 or less ________________
Domains with a score of 6 or less ____________________________________
