SELF-CARE QUESTIONNAIRE

Research has shown that individuals who dedicate time to recharge and restore themselves are generally more creative, happier, and more successful. This Self-Care Questionnaire is designed to help you identify the areas of your life that are well-tended and those that may need a bit more time and attention.

This is not a diagnostic assessment, but rather a gentle reflection tool to increase your awareness of how you care for yourself day to day. Take your time and answer each question thoughtfully. There are no right or wrong answers—only an honest snapshot of where you are right now.

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Results will be sent to your email.

A. Physical Self-Care

I get enough sleep to feel rested most days

I eat regular meals that include nourishing, whole foods

I drink enough water throughout the day

I move my body in ways that feel good to me

I schedule routine medical and dental checkups

I pay attention to my body's signals (pain, fatigue, tension)

I take time to rest when my body needs a break

B. Emotional & Mental Self-Care

I allow myself to feel my emotions without judging them

I have at least one healthy way to express or release difficult feelings (journaling, talking, etc.)

I notice when I am overwhelmed and take steps to slow down

I speak to myself with kindness rather than harsh criticism

I set boundaries when people or situations drain me

I give myself permission to say "no" when I need to

I seek support (friend, coach, faith leader, etc.) when I'm struggling

C. Mental Focus & Stress Management

I take short breaks during the day to breathe, stretch, or reset

I have at least one practice that helps calm my mind (prayer, meditation, breathing, etc.)

I can usually recognize when my stress level is getting too high

I make time to plan or organize my day so I don't feel constantly rushed

I limit my exposure to news, social media, or conversations that leave me feeling drained or anxious

D. Social & Relationship Self-Care

I spend time with people who make me feel seen, valued and supported

I can be honest with at least one person about how I am really feeling

I invest time in relationships that nourish me, not just those that need something from me

I create space from relationships that are consistently hurtful or draining

I ask for help when I need it instead of trying to carry everything

E. Spiritual / Purpose Self-Care

I make time for spiritual or reflective practices that are meaningful to me

I feel connected to a sense of purpose or "why" in my life

I regularly do something that aligns with my values (service, giving, encouragement, creativity, etc.)

I pause to practice gratitude or notice small blessings in my day

F. Rest, Joy & Play

I make time for activities that bring me joy or laughter

I allow myself to rest without feeling guilty

I take breaks from responsibilities to simply enjoy myself

I give myself permission to step away from "being productive" and just be me

G. Final Reflection

What did you notice as you completed this questionnaire?

Which area of self-care feels the most supported for you right now?

Which area of self-care would you like to gently strengthen over the next 30 days?

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I confirm that the information provided is accurate and complete. I understand that this information is confidential and will be used solely for my consultation with Life Love Wellness.

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Self-Care Questionnaire