Self-Care Assessment 2021

Self-Care Assessment
Those of us who are grieving, or have experienced life-changing events, or who care for others in our everyday lives must harness the creative ability to care for ourselves first. This self-care is a necessity. If we don’t care for ourselves, we have nothing left for others. Self-care is like the oxygen mask that falls from the ceiling on an airplane when the cabin pressure changes. The flight staff instructs us to put on our own oxygen mask first, then assist anyone around us. So we practice self-care in order to care for others.

In our self-care program, we focus primarily on The 5 Pillars of Self-Care: nutritious food, clean water, fresh air, exhilarating exercise and rejuvenating rest. I’d like to know a little about your physical self-care habits. Please answer the questions below about the 5 Pillars as accurately and honestly as possible. We will use this assessment to help develop you Self-Care Process. After you follow your process for the next four weeks, you will complete the assessment again. The improvement may astound you! It's all a matter of practice. Let's get started!
What area(s) do you feel you need the most help with? (Mark all that apply.)

Nutritious foodClean waterFresh airExhilarating exerciseRejuvenating rest
When we get sick or feel overwhelmed, we are out of balance. How does that usually show up for you? For example, do you get headaches, back aches, insomnia, chest pain, etc.
What do you do about it? For example, take medication, get rest, drink water, etc.
Nutritious Food
Do you regularly eat nutritious food?

YesNo
What is a typical breakfast?
What is a typical lunch?
What is a typical dinner?
How much fruit do you eat in a week?

1-2 servings per week3-4 servings per week5-6 servings per week1-2 servings per day
How do you usually eat your vegetables?

SteamedBoiledFriedOther
How often do you eat vegetables?

1-2 times per week3-4 times per week5-6 times per weekDaily
Are you a --

Vegetarian/VeganFruitarianNeitherOther
Clean Water
Do you feel you drink enough water?

YesNo
How many cups of water do you drink per day?
Do you drink pure water? (Not mixed with any other elements, i.e. sugar, tea, coffee)

YesNo
What kind of water do you drink primarily?

Distilled waterSpring waterPlain (no label) waterFlavored waterCarbonated waterWell waterI don't knowOther
Fresh Air
Do you get enough fresh air?

YesNo
Do you intentionally practice healthy breathing?

YesNo
Do you live in an area that contains fresh air?

YesNo
Do you smoke?

YesNoCigarettesMarijuanaother drugs
How much of each per day?

1-5 tobacco cigarettes6-10 tobacco cigarettes11-20 tobacco cigarettes21 or more tobacco cigaretes1-5 marijuana cigarettes6-10 marijuana cigarettes
Exhilarating Exercise
Do you exercise regularly?

YesNo
Exhilarating Exercise

1-2 times per week3-4 times per week5-7 times per weekmore than 7 times
What kinds of exercise do you do? Mark all that apply.

AerobicsWeight liftingwalkingRunningstretchingJumpingswimmingOther
What is your purpose for exercising? (Mark all that apply.)

Weight lossFirming/toningMaintenanceOther
Do you like exercising alone or with a group?

AloneGroup
Rejuvenating Rest
Do you get sufficient rest?

YesNo
Do you tire easily?

YesNo
Do you recover quickly (within 15 minutes) when you get tired?

YesNo
How much sleep do you get in a 24-hour period?

0-3 hours4-5 hours6-7 hours8-9 hours9 or more hours
Is it easy to go to sleep (within 15 minutes) after you lie down?

YesNo
How long does it take to go to sleep once you lie down?

0-15 minutes15-30 minutes30-60 minuteslonger than 60 minutes
Do you go back to sleep easily if you wake up in the night?

YesNo
Do you get all your sleep in one period or in broken segments and naps during the day?

one periodbroken segments and naps
Do you get sleepy during the middle of the day?

YesNo
If you get sleepy during the middle of the day, what do you do?

Take a napDrink coffee/teaTake a stimulant drugExerciseOther
Do you wake up after your night's sleep feeling rested?

YesNo
There is more to self-care than the physical. We also must attend to our mental, emotional and spiritual needs. I will help you find balance in your life when your busy world seems to be spinning out of control. I will help you assess your attitude, adjust your environment, alleviate stress and locate and get the support you need.

Please sign below, indicating your agreement with yourself tha this information is as accurate as possible so that we can properly assess where you are in the practice of the 5 Pillars of Self-Care. We need accurate information so we can develop a program with you that will help you get the balance you need. The key is to improve all areas of Self-Care to get you to a healthy place. In four weeks, we will take another assessment to see how much your newly developed program has helped you find your balance and incorporate all 5 Pillars of Self-Care into your life.
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Self-Care Assessment

Nutritious Food

Clean Water

Fresh Air

Exhilarating Exercise

Rejuvenating Rest