Welcome to your Lifestyle Questionnaire

Be as honest with yourself as possible - even if it hurts (think about your behaviours over the last month or three). Look at the scale and award your self a score accordingly (remember honesty is very important).


Name Business Email Phone Number
1. Skipping meals/dieting
2. Not exercising or exercising too much
3. Avoiding or neglecting relaxation and other ways to calm your central nervous system
4. Not getting enough sleep
5. Blowing past your own fatigue to finish the day's
6. Breathing shallowly when tense, instead of breathing deeply
7. Using sugar, caffeine, nicotine, drugs, or herbal stimulants to function at a higher rate when you are already tired.
8. Worrying. (Constantly thinking of work related issues even when you are at home relaxing).
9. Mentally replaying stressful inner dialogues.
10. Neglecting fun and relaxing activities that allow you to clear your mind.
11. You feel you are unable to meet constant demands, and you become increasingly overwhelmed and depleted of energy
12. Eating processed, junk, or fake foods.
13. Putting yourself last. (never have time to replenish your energy tank).