Name:           

Full Address:  

Postcode:      

Tel No:         

Mobile:         

Email:          

Occupation:  

Date:           


Do you see yourself as a strong person in your relationships at home?
Yes    No

Do you see yourself as a strong person in your relationships at work?
Yes    No

Would you like to find it easier to relax?
Yes    No

Please SELECT the proportion of your day that you normally feel stressed:


Do you tend to feel you need to rush things?
Yes    No

Do you like to take your time and do things well?
Yes    No

How many hours a week do you Cardiovascular exercise?

What type?


How many times a week are you in touch with friends on the internet?

How many times a week do you meet up with friends?

Do you tend to try to make things right for them?
Yes    No

How many hours a week do you take time off for you or things you enjoy doing? Hours

What is the average horus of sleep which you get per night? Hours


Is it important to you to have clear goals and achieve then?
Yes    No

Do you find it hard to get motivated?
Yes    No

Do you find it hard if you are criticised?
Yes    No

Or do you think - "Well that's their problem if they don't like what I've done. I'm OK with me.
Yes    No


Do you enjoy structure in your life?
Yes    No

Do you like to be spontaneous?
Yes    No

Do you enjoy having brain storms and creating new ideas?
Yes    No

Do you think you have a positive attitude to your everyday niggles in life?
Yes    No


Please list 3 values which are important to you - whatever comes into your head is fine.
1.      2.      3.

Do you feel you have a clear sense of purpose?
Yes    No

Do you run out of time to do the things you want to do?
Yes    No

Do you feel you are the boss at home?
Yes    No

What are the 2 emotions which you are aware you feel most?
1.      2.


Do you consider you have a spiritual base or belief system which you call upon for help and support?
Yes    No

Please describe what gives you a sense of purpose in life.

What activities/hobbies have meaning or "heart" for you?

Do you participate in voluntary community activities?
Yes    No


Have you ever had problems with your heart?
Yes    No

Has your blood pressure been high for a while at any time?
Yes    No

Detail any current or past illness or reasons for regularly having to visit your GP.


What do you do to reduce stress in your life? Running, friends, nature, exercise, cars...

What do you do which is meaningful to you to help you relax and take time for you?


Is there one person/people who you can count on for emotional support/help with a decision?
Yes    No

Is it easy for you to get angry or irritated?
Yes    No

Do you get sad/unhappy easily?
Yes    No

Can you get anxious in challenging situations?
Yes    No

Do you tend to feel lonely. Even though you have people around you?
Yes    No

Are you aware that you feel depressed at times?
Yes    No


Is there someone at work who is irritating you?
Yes    No

Are you good at standing up for yourself at work?
Yes    No

Are you good at making choices which are right for you?
Yes    No

Are you good at celebrating when life is better/good?
Yes    No


Do you enjoy helping people?
Yes    No

Do you like to feel that you are liked?
Yes    No

Are people important in your life?
Yes    No

Do you enjoy times on your own when you can simply be you?
Yes    No