Quantum Wellness Challenge
Fill out this form to the best of your knowledge to schedule a Initial Wellness Evaluation with Reiki Master / Minister of Earth SOUL Ministries Lyra. You will receive a free evaluation chart upon completion.
My Energy and Focus
Section 1
What motivates & energizes me?
How am I Feeling
Section 2: It is OK to be honest with yourself.
How I'm feeling right now.
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
How much pain (physical or emotional) am I feeling?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
How much joy (physical or emotional) am I feeling?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Internal Diagnostics
Section 3: Understanding myself
What are some things I want to improve about myself?
How do I know if my strategies for dealing with challenges are working well?
What triggers me to feel upset, angry, or sad?
What changes am I willing to make to become better?
What holds me back from being my best?
How do I best balance my time to meet my needs, my family & social activities?
Time Management
Section 4: An alternative way to view your use of time, cultivating self-aware routines empowering both your ambitions and well-being.
Please provide a brief estimate of how much time you dedicate each week to the following activities.
Days
Hours
Minutes
Work
Hobbies
R & R
Exercise
Social
Family
Education
Meditation
Other
My Strengths
Section 5: Rate the character strengths listed below each virtue in relation to you. There is no wrong answer.
Courage
10%
15%
25%
35%
45%
50%
65%
75%
90%
100%
Adaptive
Bravery
Perseverance
Honesty
Zest
Temperance
10%
15%
25%
35%
45%
50%
65%
75%
90%
100%
Forgiveness
Humility
Prudence
Self-regulation
Justice
10%
15%
25%
35%
45%
50%
65%
75%
90%
100%
Citizenship
Discernment
Fairness
Leadership
Teamwork
Humanity
10%
15%
25%
35%
45%
50%
65%
75%
90%
100%
Compassion
Empathy
Generosity
Kindness
Love
Social Intelligence
Patience
10%
15%
25%
35%
45%
50%
65%
75%
90%
100%
Confidence
Honor
10%
15%
25%
35%
45%
50%
65%
75%
90%
100%
Honesty
Integrity
Trustworthy
Knowledge
10%
15%
25%
35%
45%
50%
65%
75%
90%
100%
Love of learning
Innovative
Judgment
Wisdom
10%
15%
25%
35%
45%
50%
65%
75%
90%
100%
Creativity
Curiosity
Perspective
Spirituality
Transcendence
10%
15%
25%
35%
45%
50%
65%
75%
90%
100%
Altruism
Appreciation of beauty
Gratitude
Hope
Humor
My Community
Section 5: engaging in my community
What sectors do you identify as most important for a thriving community?
Education and Apprenticeship
Art and Music
Churches and Local Non-profits
News and Media
Private Business Sector
Workforce and Labor Unions
Public Service Sector - Local Government
Medical Health/Wellness and Fitness
Science and Technology
Family and Friends
Appointment/ Consultation
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Submit
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