First Name *

Last Name

Phone

Email *

Date of birth

There are no wrong answers, and there is no grade, no rating, and not even an interpretation of your responses other than your own thoughtful assessment. Be honest and truthful with yourself. Even when the truthful response is a little embarrassing or painful, remember that you never succeed by deceiving yourself.

-Read each statement slowly and thoughtfully.
-Rate each statement truthfully.
-Your current state does not have to be permanent. You are here to move towards balance.

Rate the following on a scale of 1 to 5, (1 being Least True and being Most True):

Nutrition

I eat my first meal within the first hour of waking up.

I eat six meals per day.

I don’t drink more than 1 caffeinated beverage per day.

I drink at least 62 oz (about 1.83 L) of water per day.

I don’t eat fast food, ever.

Movement

I do strength training at least 3x a week.

I stand up at least once every hour throughout the whole day.

I do stretching and/or yoga type exercise at least 3x a week.

I get at least 5000 steps in a day.

I go outside at least 1 hour a week.

Mindset

I review my major goals every day.

I believe that I can/will accomplish all of these goals.

I do not entertain any negative thoughts.

I read something instructional or inspirational for at least 30 minutes each day.

I always say no to requests or obligations that don’t fit my core values or objectives.

Relationships

I actively listen and communicate effectively with others to build strong connections.

I am empathetic and understanding, creating a safe and comfortable environment for others to open up.

I am sincere and authentic in my interactions, building trust in my relationships.

I am supportive and encourage growth in others, strengthening the bond in our relationship.

I regularly invest time and effort into maintaining and nurturing my relationships.

Stress

I plan my day out the day before.

I review what I am grateful for every day.

I love what I do and enjoy getting up every day to do my job.

I have a morning and evening routine.

I have undisturbed sleep for at least 8 hours each night.

Financial

I have a completely detailed budget and unfailingly stick to it.

I am credit card debt-free.

I save at least 10% of my income every month.

I have an updated and complete last will and testament.

I have a detailed retirement plan that will accommodate exactly what I need to live as I desire after retirement and for the rest of my life.

Spiritual

I consider myself a spiritual person.

I have a personal relationship with my spiritual source.

I live completely in accordance to my spiritual beliefs.

I consistently use my spirituality to help resolve my problems.

I consistently use my spirituality to help others.

Personal Growth

I am committed to continuously improving myself and reaching my full potential

I am proactive in seeking out new learning opportunities and experiences

I am determined to overcome obstacles and challenges that stand in the way of my personal growth

I regularly reflect on my progress and make adjustments to my growth plan as needed

I am dedicated to developing positive habits and traits that contribute to my overall well-being