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Name
*
First
Last
Email
*
Phone
Date of birth
*
Occupation
Health
Fitness
Selected Value:
1
1 = dissatisfied, 10 = satisfied
Appearance
Selected Value:
1
1 = dissatisfied, 10 = satisfied
Nutrition
Selected Value:
1
1 = dissatisfied, 10 = satisfied
Emotional
Selected Value:
1
1 = dissatisfied, 10 = satisfied
Mental
Selected Value:
1
1 = dissatisfied, 10 = satisfied
Body
Selected Value:
1
1 = dissatisfied, 10 = satisfied
What would you change?
Recreation
Free time
Selected Value:
1
1 = dissatisfied, 10 = satisfied
Travel
Selected Value:
1
1 = dissatisfied, 10 = satisfied
Interests
Selected Value:
1
1 = dissatisfied, 10 = satisfied
Hobbies
Selected Value:
1
1 = dissatisfied, 10 = satisfied
Physical activity
Selected Value:
1
1 = dissatisfied, 10 = satisfied
What would you change?
Relationships
Self
Selected Value:
1
1 = dissatisfied, 10 = satisfied
Family of origin
Selected Value:
1
1 = dissatisfied, 10 = satisfied
Immediate family
Selected Value:
1
1 = dissatisfied, 10 = satisfied
Work
Selected Value:
1
1 = dissatisfied, 10 = satisfied
Partner
Selected Value:
1
1 = dissatisfied, 10 = satisfied
Sex life
Selected Value:
1
1 = dissatisfied, 10 = satisfied
Friendships
Selected Value:
1
1 = dissatisfied, 10 = satisfied
Community
Selected Value:
1
1 = dissatisfied, 10 = satisfied
What would you change?
Personal development
Spiritual
Selected Value:
1
1 = dissatisfied, 10 = satisfied
Emotional
Selected Value:
1
1 = dissatisfied, 10 = satisfied
Mental
Selected Value:
1
1 = dissatisfied, 10 = satisfied
Self-mastery
Selected Value:
1
1 = dissatisfied, 10 = satisfied
New skills
Selected Value:
1
1 = dissatisfied, 10 = satisfied
What would you change?
Career
Enjoyment
Selected Value:
1
1 = dissatisfied, 10 = satisfied
Colleagues
Selected Value:
1
1 = dissatisfied, 10 = satisfied
Remuneration
Selected Value:
1
1 = dissatisfied, 10 = satisfied
Purpose
Selected Value:
1
1 = dissatisfied, 10 = satisfied
What would you change?
Submit