Full Name *

Email *

I am up-to-date with my optician, dentist and other health check-ups *

Yes

Sometimes

No

I am happy with my physical fitness and energy levels *

Yes

Sometimes

No

I eat well nutritionally most of the time and do not abuse my body with caffeine, alcohol or similar *

Yes

Sometimes

No

I have plenty of sleep so I always feel well rested *

Yes

Sometimes

No

I take regular breaks from my work during the day, at weekends and use my holidays for enjoyment & relaxation *

Yes

Sometimes

No

I like how my hair is at the moment, I am happy with my wardrobe and my 'style' *

Yes

Sometimes

No

I meditate, journal, quietly relax or have alone-time with myself regularly (where I am not doing anything eg. chores or doing things for others) *

Yes

Sometimes

No

I prioritize how I spend my time and important things always get done in plenty of time *

Yes

Sometimes

No

I say "No" to myself and others when I need to *

Yes

Sometimes

No

My home is cleaned regularly to a standard I am happy with *

Yes

Sometimes

No

My home is organized and tidy and somewhere I love to be *

Yes

Sometimes

No

My home is a calm haven (or has a place within it) that takes me away from the stresses of the world *

Yes

Sometimes

No

I recognize my stress signals and know when to take a break *

Yes

Sometimes

No

I have enough people in my life who love and support me *

Yes

Sometimes

No

Apart from exceptional situations, I only spend time with people who support, energize and inspire me *

Yes

Sometimes

No

I listen to and trust my intuition when it comes to looking after me *

Yes

Sometimes

No

I have a mentor/s that support and encourage me in life *

Yes

Sometimes

No

I have no regrets and have forgiven myself my past mistakes *

Yes

Sometimes

No

I have let go of any past resentments towards others *

Yes

Sometimes

No

I have reserves of things that are important to me or help my life run smoothly (anything from contact lens solution to pens, paper, vitamins or bathroom tissue!) *

Yes

Sometimes

No

I have things to look forward to in my life *

Yes

Sometimes

No

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