The 20 Point Self Assessment Questionnaire

Note: This is a personal, private and completely confidential….for your use only! Please be as open and as honest as possible. Don’t hold back anything.

Write names or events in “code” if necessary!

Be brutally honest!

These questions will help you access your concerns during this program and the body balancing procedures. This is a must!

(1) Name (any name you have ever gone by) ________________________________

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(2) List the most significant positive event in your life. ___________________________
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(3) List the worst thing that ever happened to you in your life. _____________________
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(4) Have you ever had your heart broken by someone or something? _______If so, write

it down. _______________________________________________________________

(5) What positive event are you looking forward to in the future? __________________

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(6) What negative event(s) are you dreading in the future? ________________________

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(7) What time of day do you feel the best? ________ Worst? ______ Do you rely on your doctor to heal you? ______ Do you take active measures to heal yourself? ______

Do you rely on drugs, pain relievers, or sleep aids to just get by? ___________________

(8) What excites you most about your business, job, occupation, school? ____________

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(9) What frustrates you most in your job, fun in relationships, school, etc.? ___________
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(10) Who in your family do you have the most challenges with? ___________________

Is there anyone you have intentionally not spoken to in years? ____________ What about your primary relationship (family, spouse, etc.) excites you the most? _________

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Challenges you the most? __________________________________________________

(11) Have you ever been totally in love? _______ Now? ________________________

(12) Do you earn enough money? ______________ Have enough? __________ Stress over money? ________ Have a plan for more money? ___________ Do you feel confident your money plan will take care of your family? __________________

(13) Do you love life? _____________ Are you depressed about life? ___________ Are you attracting friends and relationship and circumstances that you like/love/and that enrich your life? __________________

(14) Do you know how to listen to what your body tells you? _________ How often do you exercise? ________ Do you say affirmations or belief builders every day? ______

(15) Do you find yourself in arguments often? _____ Do you have to win? _________

Are you always right? ______ Are you flexible? ______ Do you often think about or actually interrupt a conversation? _______ Do you 1-up someone often? _________

(16) Are you growing and learning right now? _______ How often do you interrupt a conversation with … “I already know that!” _________ How many times a day, if ever do you say “I’m sorry”? __________________________

(17) What do you think made you sick or why are you sick? _____________________

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(18) Do you believe you are worthy of getting well...ever? _____ In three days? ______

Right now? _______ Do you blame God for your condition? _____ Daily? _________

(19) Do you have a set of goals or a plan for health? ________ List the top three goals for the year for your return to great health. _____________________________________

(20) How often each week do you eat out? ________________ Do you think organic foods are better or just more expensive? ___________ Do you eat them? _______ How often do you consume alcohol, caffeine, diet foods, cigarettes? ______ 1, 2, 3 times day or more? ________ Do you eat anything labeled DIET? ______ 1, 2, 3 times a day or more? __________