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Domain 1 – THOUGHT BALANCE 1. I have trouble concentrating if something is bothering me.
2. When I get angry, I sometimes say or do something I later regret.
3. Somedays, I am overwhelmed with information.
4. I spend more than eight hours a day on the computer, laptop, or iPhone looking at social media, texts, emails or other informational platforms.
5. I realize that some information I hear or see is not helpful, but I still watch or listen to it anyways.
6. I am influenced by what other people say.
7. I sometimes think that all the information my brain takes in on a given day affects parts of my life like my sleep, my emotions or other areas of my life.
8. I know how to reduce or eliminate negative thoughts.
10. I sometimes cannot prioritize things that are most important verses what is least important to do on a given day.
After the 10th question, on a scale of one to 10 stars with one star being unbalanced, and 10 stars being completely balanced, punch the appropriate number of stars.
Domain 2 – EMOTIONAL BALANCE 1. I get emotional if things don't go my way
2. I let things build up until I can't take it anymore
3. I can always control my emotions.
4. I can be emotionally influenced by what other people say or do.
5. I feel like it’s okay to show or express your emotions.
6. I believe it’s better to keep your emotions to yourself.
7. I would rather show a ‘happy face’ to others even when I feel otherwise.
8. I believe that your emotions are a true expression of who you are as a person and you should not hold them back.
9. When I get angry at someone and yell, I regret it later and feel physically exhausted as well.
10. My best friendships have been with people who I can emotionally connect with.
After the 10th question, on a scale of one to 10 stars with one star being unbalanced, and 10 stars being completely balanced, punch the appropriate number of stars.
Domain 3 – PHYSICAL BALANCE 1. I get 7-8 hours of sleep a night.
2. I walk or run four miles (approximately 10K steps), a day.
3. I have an annual physical exam every year.
4. I consider myself overweight
5. I take fitness classes and/or workout at my local gym 3+ times a week.
6. I take my physical fitness seriously.
7. I feel like it is easier to get injured as I get older when I don’t work out.
8. I like to play sports or to participate in physical activities with friends or family.
9. It’s hard for me to set physical fitness goals.
10. I believe being physically fit can improve my overall health and well-being.
After the 10th question, on a scale of one to 10 stars with one star being unbalanced, and 10 stars being completely balanced, punch the appropriate number of stars.
Domain 4 – NUTRITIONAL BALANCE 1. I think about what I am going to eat, whether its vegetarian food, protein or other foods.
2. I plan for what times I am going to eat throughout the day.
3. I eat three meals a day.
4. I check the ingredients of the foods I buy.
5. I eat a lot of carbohydrates, sweets or snacks.
6. I drink more than one glass of wine, beer or cocktail more than once a week.
7. I check the calories of the foods before I buy.
8. If I see a snack on sale (e.g. buy 2 Cheetos and get the 3rd one free!), I am likely to buy it.
9. I eat desert more than 3 times a week.
10. I regularly buy soda at the supermarket.
After the 10th question, on a scale of one to 10 stars with one star being unbalanced, and 10 stars being completely balanced, punch the appropriate number of stars.
Domain 5 – SPIRITUAL BALANCE 1. I believe in a higher power.
2. I practice my faith regularly.
4. When something bad happens, I just accept it or rationalize it.
5. I believe in miracles.
6. I take responsibility in my daily life and turn to my higher power when things happen beyond my control.
7. I have friendships and relationships with people who think like me.
8. I reflect and appreciate when unexpected, good things happen in my life.
9. If someone close to me dies, it makes me question my faith.
10. I respect people who have different spiritual beliefs than I do.
After the 10th question, on a scale of one to 10 stars with one star being unbalanced, and 10 stars being completely balanced, punch the appropriate number of stars.
Domain 6 – WORKLIFE BALANCE 1. I look at work as a challenge.
2. I sometimes feel unorganized at work.
3. I have difficulty balancing all the work and personal things I need to do each day.
4. I feel overwhelmed by work requirements at the expense of other areas of my life.
5. I have a hard time adjusting to all the new technologies like AI.
6. I value my job and the role I play in the company.
7. I see the value in developing a work-life balance routine.
8. I manage sudden changes in my daily routine well.
9. I check my work email all hours of the day.
10. I place my work above everything else in my life.
After the 10th question, on a scale of one to 10 stars with one star being unbalanced, and 10 stars being completely balanced, punch the appropriate number of stars.
Domain 7 – SOCIAL BALANCE 1. I get social interaction and fulfillment by watching movies.
2. I get connected socially mostly through social media.
3. I have three friends who I can call in an emergency.
4. I am close to members of my family.
5. I have close friendships at work.
6. I participate in social events in my community.
7. I participate in social and/or athletic events like attending a concert, going to a football game or watching fireworks.
8. I enjoy traveling to different states and countries and meeting new people as well.
9. I spend more than two hours on social media a day, four or more days a week.
10. I identify myself as socially shy or an introvert around people.
After the 10th question, on a scale of one to 10 stars with one star being unbalanced, and 10 stars being completely balanced, punch the appropriate number of stars.
Domain 8 – FINANCIAL 1. I pay off my credit cards each month.
2. I put money aside into a savings account each month.
3. I currently contribute or have contributed to a 401K or retirement account.
4. My partner and I have a dual account to pay shared bills.
5. I often spend without thinking about the price.
6. I participate in the stock market.
7. I go out to a restaurant more than once a week.
8. I believe in saving up for something big like a car, or condo or a vacation.
9. I have written down some financial goals in the past and have fulfilled those goals.
10. I live within my means.
After the 10th question, on a scale of one to 10 stars with one star being unbalanced, and 10 stars being completely balanced, punch the appropriate number of stars.
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