Emotional Self-Care
1. Are you able to identify and label your emotions as you experience them?
2. Which of the following statements is most true to you?
3. When you experience a negative emotion (eg. irritability, anger, sadness) how do you cope with it?
4. Which of the following coping mechanisms, or ways/activities to manage stress, do you use? Check all that apply.
5. How would you answer this statement: I feel hopeful and optimistic about the future.
6. Which statement would you say most accurately describes you?
Physical Self-Care
1. How often do you exercise?
2. Do you get at least 7 hours of sleep each night?
3. How would you describe your nutrition and diet?
4. Do you routinely shower/bathe, wear clean clothes, and groom yourself daily?
5. Do you go to annual medical appointments (annual check-ups, dental cleanings, etc)?
6. How would you describe your libido (sexual desire or interest in engaging in sexual activity)?
7. How much caffeine do you consume each day?
8. On average, how many alcoholic drinks do you consume weekly? (12 oz. beer or 5 oz. wine or 2 oz. liquor)?
9. Has your alcohol use caused problems or issues in your personal life, relationships, at work or resulted in legal issues (eg. driving intoxicated, assault, or disorderly conduct charges)?
10. Do you skip eating meals?
11. Do you use food as a way to cope with your feelings or manage stress?
12. Do you nap or sleep as a way to avoid dealing with the stress or challenges in your life?
13. Do you use alcohol as a way to unwind and relax?
Mental/Cognitive Self-Care
1. Would you describe your days as interesting and mentally stimulating?
2.How would you describe your mind's daily mental chatter, also described as self-talk?
3. How often do you experience flow, the experience when you are doing something you love and enjoy and lose track of or forget about time?
4. How would you describe your memory and ability to recall information?
5. How often do you feel bored?
6. Do you have hobbies and interests that you engage in?
Social Self-Care
1.Which statement most closely describes your friendships?
2.Would you describe your immediate family as supportive?
3. If you needed help because of an illness or injury, would friends and family be available for help?
4. If you wanted to go on a day trip, outing, or event, could you easily find someone to go with?
5. What statement most closely describes the relationship with your significant other/partner/spouse?
6. Do you feel a sense of belonging and importance within your social relationships?
Spiritual Self-Care
1. Do you spend time outside observing and enjoying nature?
2. Do you find meaning and purpose in your day whether at home, work, or in your community?
3. Do you think you make a difference in the lives of others?
4. If you are part of a religious group, do you attend or participate in religious rituals and/or services? (this question is not graded)
5. Do you feel a sense of connection to others, not only those you know, but also in your community and the world in general?
6. Do you spend time in prayer? (this question is not graded)
7. Do you meditate?
8. Do you routinely express gratitude in your life?
9. Do you take time to reflect on what is important to you in life?
Is there a topic or concern you would like to learn more about?
Personal Information
This section is not scored. It is only gathered for information purposes and demographic research.
* First Name:
Last Name:
* Email:
Age range:
Marital Status:
Number of children:

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