| E-mail Address: * |
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| I often eat foods that are healthy and nutritious. |
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| I rarely feel tired by mid-afternoon, and use for more energy coffee, soda or a candy bar. |
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| I try to include some type of cardio activity into my daily routine. (i.e. walking, running, etc) |
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| I prefer to walk up one or two flights of stairs rather than take the elevator. |
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| I sleep eight hours on most nights. |
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| I get routine health checkups on a regular basis. |
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| I have been successful in maintaining my ideal body weight. I am proud of my body. |
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| An integral part of my leisure time includes physical activity instead of TV viewing or surfing the net. |
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| I do not have any health conditions * |
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| I recover well from illness. * |
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| My self-esteem is not defined by my body image. * |
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| I have a high level of self-confidence. * |
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| I have a way to relax that eliminates stress and keeps me centered. * |
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| I understand that I am more than what I do. * |
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| I have been able to successfully handle stress more than usual lately. * |
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| I feel my body and mind are in perfect harmony. * |
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| I keep my mind alert by enrolling in courses, reading, and learning new things each day. * |
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| I am happy and content with my spouse/partner, or happy being single. * |
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| I feel encouraged when I meet someone that reflects what I want for myself. * |
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| I know what my goals are and I am eagerly and effectively making them a reality. * |
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| I call on a higher power in times of need. * |
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| I feel that I am never too old to change. * |
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| If I discovered that major changes were needed in my life, I would be more than willing to make them. * |
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| I pay close attention to my health and well-being * |
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| I am completely happy with the life I have created for myself. * |
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| I am open to finding new ways to improve myself. |
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| I feel a sense of accomplishment by helping others * |
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| I am satisfied with accomplishing small tasks that contribute to a larger goal. * |
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| I believe that my past experiences can help me reach my future goals. * |
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| I get most of my strength from family, friends, or group support systems. * |
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| I see coaching as a worthwhile investment in providing structure and support in reaching my goals. * |
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| I can pay the coaching fee. * |
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| I am willing to do the work and let the coach do the coaching. * |
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| I feel that I would be interested in working with a coach in a group setting. * |
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| I feel that I am interested in attending personal development workshops or seminars. |
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| * Required |
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353 Jonestown Road Ste 230
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