HEALTH ASSESSMENT INSTRUCTIONS:
Answer yes or no to each question
in all five categories. If the statement
is sometimes or usually true, do not answer yes until the statement is ALWAYS
true for you. If the statement does not
apply to you, disregard it.
How long it takes you
to complete the program is up to you.
Work on it as often as you like until all of your answers have become
YES answers. You will find a renewed
energy and sense of well being as you make changes in the areas of home
environment, nutrition, and physical, emotional and spiritual health. You may want to print out this survey and keep it
in a place
where you will see it often as a reminder to keep working on it.
HOME ENVIRONMENT:
1. My home is my sanctuary from the world
2. I have a space in my home to exercise
2. I have a space in my home to exercise
3. I have cleared out items I don’t need or use
4. People feel comfortable and welcome in my home
5. I can walk without tripping over things
6. I have a system for filing all papers
7. I make my bed every day
8. My appliances are all in working order
9. There is music in my home
10. My home is neat and clean most of the time
11. I have my own space to relax and take care of myself
12. My clothes are clean and in good repair
13. I clean with environmentally friendly products
14. I have live plants in my house
15. I recycle as much as I can
16. I sleep in a dark, quiet room that is clean and comfortable
17. If there are pets, they are healthy and clean
18. I surround myself with beautiful things that I love
19. I live in a neighborhood/area that I love
20. The air quality in my home is good
21. I have clean, filtered water to drink
22. I have filters on all shower heads
23. My home smells good
24. I have a clean, organized pantry
25. I feel relaxed and at ease in my home
List one thing you will do this week to change a no answer to a yes. Continue to do so until you have answered yes to every question.
Date: _____________
This week I will _____________________________________________________________________.
PHYSICAL HEALTH:
1. My hearing and eyesight are good
2. I do some kind of physical activity every day
3. I brush my teeth at least twice a day
4. I floss daily
5. I do not have any major aches or pains
6. I do not use or rarely use caffeine
7. I do not use alcohol or illegal drugs
8. I take a vacation at least two weeks a year
9. I do not work more than 40 hours a week
10. I am not addicted to any food or substance
11. I have had a physical exam in the last year
12. I only take medicine if I absolutely have to
13. I have no habits which I find unacceptable
14. I have ways to deal with the stress in my life
15. I practice deep breathing techniques
16. My weight is within normal range
17. I have visited the dentist in the last 6 months
18. I do not need to rush or hurry to get things done
19. I do not smoke or use tobacco
20. I do not eat past the point of comfort
21. I have regular bowel movements
22. My digestive health is good
23. My hair and nails are healthy and look good
24. My blood pressure is within normal range
25. I do not have high cholesterol levels
List one thing you will do this week to change a no answer to a yes. Continue to do so until you have answered yes to every question.
Date: _______________
This week I will ____________________________________________________________________.
EMOTIONAL HEALTH:
1. I say “I love you” to my family members regularly
2. I have something to look forward to each day
3. I feel happy when I wake up in the morning
4. I like my boss
5. I get along with my siblings
6. I enjoy what I do for a living
7. I have a best friend
8. I do not gossip about others
9. I look for solutions rather than complain
10. I do not take things personally
11. I feel loved by my friends and family
12. I have good communication skills
13. I feel accepted for who I am
14. I like myself
15. I am honest and trustworthy
16. People like being around me
17. I forgive others who have hurt me
18. I am not judgmental or critical of others
19. I let someone know when they hurt my feelings
20. I am aware of my own needs and take care of them
21. I call return phone calls and answer emails
22. There is no one I dread running into
23. My life is satisfying and happy
24. I do not spend more than I earn
25. I let go of toxic relationships
List one thing you will do this week to change a no answer to a yes. Continue to do so until you have answered yes to every question.
Date: _______________
This week I will ____________________________________________________________________.
SPIRITUAL HEALTH:
1. I take time each day for stillness and reflection
2. I go for walks outdoors on a regular basis
3. I read uplifting and inspiring books
4. I feel connected to a higher power
5. I pray daily
6. I express gratitude frequently for blessings
7. I look for ways to serve those around me
8. I have friends who support my beliefs
9. I am a good example to my children
10. I speak only good of others
11. I feel the guidance of God’s Spirit in my life
12. I feel the presence of loved ones who have passed
13. I feel worthy of God’s love
14. I ask God to forgive my mistakes
15. I always try to learn new things
16. I believe in the goodness of all people
17. I have a religious practice
18. I respect the beliefs and choices of others
19. I let people know what I believe
20. I make sacrifices for others
21. I am willing to admit when I am wrong
22. I trust that God is in control of my life, not me
23. I feel calm and at peace
24. I try to improve myself each day
25. I believe God has a plan for me
List one thing you will do this week to change a no answer to a yes. Continue to do so until you have answered yes to every question.
Date: _______________
This week I will ____________________________________________________________________.
NUTRITION:
1. I drink at least 75 oz. of water daily
2. The majority of my food is cooked at home
3. I like to eat a variety of foods
4. I avoid eating too much sugar
5. I love vegetables
6. I have visited a farmer’s market
7. I grow some of my own produce
8. I cook with fresh herbs and spices
9. I buy at least some organic foods
10. I read food labels and know what they mean
11. I “shop the perimeter” of the grocery store
12. I make healthy choices that nourish my body
13. I eat foods that were recently alive
14. I know how to make a green smoothie
15. I chew slowly and enjoy my food
16. I eat in a quiet, settled atmosphere
17. I don’t eat when I am upset
18. I give thanks for the food I eat
19. I eat when hungry and stop before I’m full
20. I listen to my body
21. I know what my cravings mean
22. My diet is fresh and colorful
23. I have a healthy relationship with food
24. I do not punish myself by withholding food
25. I never skip meals if I can help it
List one thing you will do this week to change a no answer to a yes. Continue to do so until you have answered yes to every question.
Date: _______________
This week I will ____________________________________________________________________.
For more information about Health Coaching with Linda Barney, visit
www.lindabarneyhealthcoach.com.
