Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
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Please describe a normal day of eating.
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How many meals? What is typically a part of each meal? How often do you snack? Do you binge eat? Answer with as much detail as possible.
I am physically strong.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I feel that I am physically fit.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I fall asleep easily and sleep soundly.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
Approximately how many hours do you sleep a night?
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Less than 4 hours
4-5 hours
5-6 hours
6-7 hours
7-8 hours
More than 8 hours
Do you wake up multiple times a night?
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Yes
No
I have more than enough energy to meet all of my daily responsibilities.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
Do you consume any of the following stimulants or supplements?
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Please check all that apply.
Coffee
Energy Drinks
Dietary Supplements
Vitamin / Nutrient Supplements
Nootropics
Sleep Aides
Other
None
Please describe details on current stimulants or supplements.
How often do you engage in physical workouts or exercise?
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Never
Rarely (once every few months)
Sometimes (about once a month)
Occasionally (once every few weeks)
Weekly
Daily
Multiple times a day
Please describe what typical exercise looks like for you.
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Walking. Weights. Cardio. Running. Swimming. High-intensity interval training. Bodyweight. Yardwork.
Use as many descriptions as necessary. If your exercise is sparse, please include what may be involved in physical movement.
I am free of chronic aches, pains, ailments, and diseases.
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Strongly Disagree (Constant issues)
Disagree
Sometimes
Agree
Strongly Agree (No issues)
Not applicable
Please describe any of the issues you experience as noted above.
Do you take medication for medical or physical issues.
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Yes
No
Please describe the above medications.
Which drugs do you consume.
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Check all that apply.
Caffine
Nicotine
Alcohol
Artificial Sugar
Depressants
Stimulants
Cannabis
Hallucinogens
Opioids
Synthetic Drugs
Prescription Drugs
Steroids
Other
None
How often do you consume drugs as noted above?
Never
Rarely (once every few months)
Occasionally (once a month)
Semi-Regularly (every few weeks)
Regularly (weekly)
Daily
Please describe your drug use and/or offer any clarification on your drug use.
I have specific goals in my personal and professional life.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I have the ability to concentrate for an extended period of time.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I believe that it is possible to change.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I have no problem meeting my financial needs and desires.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I have an optimistic outlook on my life.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I make it a habit to use positive affirmations.
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Strongly Disagree (Never)
Disagree
Sometimes
Agree
Strongly Agree (Always)
Not applicable
What is your career or occupation?
What is your job(s) or career(s)? Please include per diem work or a description of your central occupation (e.g., stay-at-home parent).
My career or occupation is satisfying and utilizes all of my gifts and talents.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I am willing to take risks or make mistakes in order to succeed.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I maintain peace of mind and tranquility.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
Please describe any of the above practices.
Please describe the above medications.
I am free from a strong need for control or the need to right.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I am aware of and am able to safely express fear.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I am aware of sadness and am able to safely express sadness and cry.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I feel able to accept all of my feelings - both positive and negative.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I have disturbing dreams.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I have a high level of self-esteem and self-respect.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I actively commit time to my internal awareness, well-being, and spiritual development.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I frequently contemplate the wonder of my life and the mystery of existence.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I listen to and act on my intuition.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I like to challenge my limits and risk growth (including embracing new experiences).
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I embrace spirituality and mystery.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
How often do you make a conscious effort of gratefulness for the gift(s) or your life?
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I consistently engage with the natural world.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I feel a strong sense of purpose in my life.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I have demonstrated the willingness to commit to long-term relationships.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I consistently connect with my family and make intentional time for it.
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Strong Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
Please describe relational issues that may be negatively impacting your holistic health.
Playfulness and humor are important in my daily life.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I have the ability to forgive myself and others.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I am able to confide in and speak openly with one or more close friends.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I have/had a close relationship with my parents.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I have been able to fully grieve the loss of loved ones in my life.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
Please comment on any of these non-death losses and how you have grieved or not grieved.
My experience with pain and loss has enabled me to grow as a person.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
How often do you go out of your way to help others?
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I perceive my worth by how correct or ideal I am.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I perceive my worth by how helpful I am to others.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I perceive my worth by whether people think I'm successful or good.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I tend to keep people distant and am only loyal to a select few.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I rebel against norms and take pride in being unique.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I prefer keeping peace and avoiding conflict, even if it is at the expense of my own well-being or other's well being.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I feel a sense of belonging in a group or community.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable
I experience genuine, unconditional, and authentic love.
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Strongly Disagree
Disagree
Sometimes
Agree
Strongly Agree
Not applicable