Section 1: Choose Yes/No

Do you give more than 10% of your income?

Do you work out two times or more per week?

Do you watch less than 4 hours of TV per week?

Do you have a bucket list?

Do you follow a particular set of rules for selecting which foods you eat?

Can people closest to you count on you to do what you’ll say you’ll do?

Do you have a list of affirmations written out that you can access when needed?

 Do you have some clearly defined goals for the year?

Do you feel enriched spiritually?

Are you maximizing your potential in professional endeavors?

Section 2: Rate Yourself 1-10 (low-high)

Self-confidence in front of others

Self-esteem and self-image

Passion in your past or current romantic relationships

Motivation to stay physically fit

Peace in relation to your finances

Relationships with friends in terms of richness

Eating habits in terms of healthiness

Ability to achieve goals

Level of potential that you are currently operating at

Your ability at saying Thank You

Section 3: Rate yourself (Sometimes, Always, Never)

You follow a written detailed schedule of how you'd spend your time in a perfect week.

You have a weekly date night with your significant other (or friends).

You know the exact balance of all of your financial accounts.

You engage in weekly spiritual fellowship.

You accomplish the things you put your mind to.

You get enough sleep each night.

You are effective at recognizing others for their contribution to your life.

You consciously monitor and intentionally shape your inner dialogue every day.

You follow through on your commitments.

You stay spiritually connected and enriched.

Section 4: True or False

You have a game plan at the start of every day.

You have a clearly defined purpose for your life.

Your romantic relationships are exciting and passionate.

You have a general belief that things will work out for the best.

You have a detailed plan for how to accomplish your financial goals.

You engage in meaningful regular conversations with your family.

You read books.

You are in good shape.

You have a good system for managing your money.

You are held accountable to things you want to achieve.