Please fill out this
Short Form to Help Me Understand
Your Current Self-Care

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Name

• What are the First 3 Things you Do As Soon As You Wake Up?

Please Check The Box That Would Best Describe Your : Sleep

Great

Good

Needs Work

Please Check The Box That Would Best Describe Your : Water Intake

Great

Good

Needs Work

Please Check The Box That Would Best Describe Your : Overall Health

Great

Good

Needs Work

What is your Stress Level 1-10 ( 1 being NONE - 10 Extreme ) on daily bases

What Do you Normally Eat ( more than 3 times a week)

Fruit

Vegetable

Gluten

Dairy

Processed Foods

Fast Food

Candy

Soda

MEDIATE: How many Times a Week & for How Long

Do You Ground / or do Earthing?

Yes

What is Grounding

How much time are you out in Nature? ( Per Month )

1-2 times

3-4 times

5+ or more

Do you go out for a Walk 3 times a week?

Yes

How Many Times Per Week do you Exercise?

Once

Twice

Three

Four

Five

Six

Daily

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