Feel free to print this out twice for those who may want to do a "before" and "after" comparison.
1. Observe your body. How does your it feel?
Are there any areas of tension? Where are they?
For each of discomfort, pain or tension, describe the intensity on a scale from 1 (lowest) to 10 (highest)
What percent of you day is in the discomfort?
Are there times when it is amplified? Reduced? When?
2. How would you rate your energy level?
1 (lowest) to 10 (highest)
Observe if it varies with the time of day, people present, food eaten or activity.
Make observations as to your energy patterns.
3. If you have an illness or addiction, notice patterns and record.
What events or situations trigger the problem?
When is it most severe?
What percent of your day or week is most problematic?
What side-benefits can you find within this problem?
Can you replace the benefits with other more self-loving activities?
4. What patterns and behaviors do you wish to release?
ex: establishing boundaries such as not being able to say "no"
afraid to reveal your real self
smoking, gambling etc.
negative thinking, over-spending, stress eating, alcohol addiction
Note how often you partake in the above per week or per day as appropriate.
5. What is the quality of your relationships?
What percent of your relationships are harmonious?
Are you authentic in your relationships?
Do you hold back from expressing your honest feelings?
Do you often feel like a victim?
Do you feel nurtured and supported by your loved ones?
How often do you choose to support yourself? How does it feel?
Do you give your power away?
Does anger come up when you assert yourself, or do you calmly state
your needs knowing you deserve them?
Would you like to see changes in your relationships? How?
6. What situations set you off and put you out of control?
How long are you incapacitated? Minutes? Hours? Days?
What is your typical reaction? Do you lash out? Withdraw? Cry? Feel helpless?
What would you like to see improve in this area?
7. Are there areas in your life that you feel "stuck"?
How does staying stuck serve you? How does it protect you?
Do you really want to move forward?
If not, what are you choosing to be your reason for staying stuck?
How would moving forward serve you?
What percent of you is ready to change?
How supported do you feel about life?
What would you like to change that you feel has held you back?
8. How clear is your ability to solve problems?
Does your mind run in circles?
Are you too full of fear or anger to see clearly?
What percent of your day or week do feel clarity and in control?
Would you like to see any changes in this area? What are they?
9. Notice your inner peace to anxiety ratio.
What percent of your day is peaceful?
10. How are your sleep patterns?
How often, if at all, do you get up in the night?
What is the quality of your sleep?
11. What percent of your inner dialogue is positive, optimistic and supportive?
What percent of your thoughts are negative, fearful, and hopeless in nature.
12. What is the quality of people and situations you draw to yourself?
What percent are supportive?
What percent are destructive?
13. How much in control do you feel about your life?
Use a percent to represent your feelings of control.