Pre-Assessment Questionnaire

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Contact Details

Your Name *

Mika Botkin

Your Email *

mika@curingkindness.com

Contact Number *

5144422272

City *

MOntreal

State/Province *

quebc

Country *

Canada

Physical Health

How physically active are you? *

Very! I try to make time to sweat every day.

Quite active. I get a good workout in, 3-5 times a week.

Minimally. I just can’t seem to make it happen.

Active? Pass me the remote control and I break a sweat.

I’m not currently active but want to start.

How would you describe your general immunity? (Catching colds, flus, etc…) *

I’ve got a bug proof immune system.

I rarely get sick, but it can happen once in a while.

I seem to catch what’s going around more often than I’d like.

I struggle with chronic illness.

To what degree do you struggle with aches, pains, or unwanted body conditions? *

Not at all!.

Rarely get aches and pains.

I have a lot more than I’d like.

I feel like I’m constantly struggling with something.

How much attention do you have on the health of your body? *

I think about it all the time.

It’s a frequent concern for me.

Not very often, I’ve got my mind on other things.

How consistent is your sleep pattern? *

I’m a master of slumber. I get 7-8 hours of sleep almost every night.

My sleep is inconsistent, and I often feel tired or sluggish.

I struggle with insomnia or poor-quality sleep.

I rarely get more than 4-5 hours of sleep.

How would you describe your current diet? *

I mainly eat balanced, whole-food meals.

I eat a mix of healthy and processed foods.

My diet is mostly processed and convenience foods.

I often skip meals or eat irregularly.

How often do you feel mentally and emotionally clear and focused? *

I feel clear-headed and focused most of the time.

I have moments of clarity, but often feel scattered.

I frequently feel overwhelmed and struggle to focus.

I rarely feel mentally clear and I often feel stuck in my thoughts.

Lifestyle Habits

How would you describe your personal beauty care habits? *

Au naturel! I don’t put a single thing on my skin.

I stick to natural or organic skincare and cosmetics.

I like to invest in my products, but they’re not necessarily natural or organic.

I kind of just use what seems to work

Other: ________

What kind of cleaning products do you use in the home? *

Baking soda, vinegar, and essential oils.

The healthiest stuff I can find at the store.

Mr. Clean, Pinesol, and Windex are on my cleaning menu.

How would you describe the state of your possessions? *

Everything is in pristine condition.

Pretty good, but some things are a little neglected.

Often seem to be surrounded by broken things that need fixing.

I live out of a duffle bag.

To what degree would you consider yourself an organized person? *

Try and find something out of place. I dare you.

I’m pretty organized!

I struggle to keep order but trust me, I know where everything is.

Chaos and mess are my modus operandi.

If you were to take pictures of your bedroom, kitchen, bathroom, office, and living room, how would you describe the condition of your space? *

Everything is clean, organized, and exactly where it should be.

Things are mostly tidy, with just a few areas needing attention.

My space is often messy or cluttered, but I can find what I need.

Things feels chaotic and disorganized most of the time.

How often do you take time to be present in your environment without distractions (e.g., taking a walk, spending time in nature)? *

Every day

A few times a week

Occasionally

Rarely or never

Are you currently taking any psychiatric medications or using recreational drugs? *

No, I don’t use any of these.

Yes, but I am willing to take a break for the duration of the program.

Yes, and I am unsure about taking a break.

Yes, and I rely on them regularly.

Communication & Relationships

How confident are you in your ability to study and learn new concepts effectively? *

I speed read. I gobble books like an intellectual snack in my past time.

I feel pretty sharp and attentive and can learn what I want when I put my mind to it.

I sometimes doubt my ability to study and retain information, but I am ok.

I have had significant struggles with learning and been told I have a “label” that limits my ability to learn.

How would you describe your general attitude toward life? *

Fan-freakin’ tastic.

Life is pretty good, overall.

I find life is frustrating and difficult.

Sigh.

Are there any significant relationships causing you stress or concern right now? *

HECK YA!! I get all red in the face just thinking about it!

There are a few people that cause me grief.

Nothing that comes to mind. Family and friends are all great, supportive people.

How do you feel about the quality of your communication in your relationships with others? *

Great! I enjoy my relationships with other people and communicate comfortably.

Seems my conversations often end up in arguments and disagreements.

I prefer to avoid difficult conversations and so keep more to myself.

I struggle to communicate effectively with others.

How would you describe your ability to speak your mind? *

I communicate my concerns and ideas easily with everyone in my life.

I share what I think with a few close people.

I tend to keep my feelings to myself.

I rarely seem to be able to tell people what I really think.

How often do you find your thoughts dwelling on past events? *

Rarely, I’m usually focused on the present or future.

Occasionally, but I can redirect my attention.

Frequently, I struggle to stay in the present.

Almost constantly, my mind is stuck in the past.

How would you describe your ability to bounce back after difficult experiences? *

I’m up and at ‘em in no time stronger and better for it.

I can usually move on after some time and space to reflect.

I struggle to let go of the past and hold some resentment about things.

Grrrrrrr… sob, sob.

How would you describe your ability to get things done? *

I rock my to-do list like a ninja!

I feel pretty good about what I get done and how I do it.

I struggle to manage everything on my plate.

I’m totally and completely overwhelmed.

To what degree do you feel you can “be yourself” around other people? *

I let ‘er rip and keep it real! All me or nothin’!

I feel comfortable being myself most of the time.

I’m cautious and selective about who sees the real me.

I rarely feel like I can be myself around others.

Study, Goals and Motivation

Please describe where you would like your health and attitude toward life to be in the next 12 months. *

What do you perceive will be your biggest obstacles in getting there? *

What will happen if you don’t make any changes to your health or lifestyle? How does that make you feel? *

If you could wave a magic wand and change one thing about your body or your health, what would that be? *

How committed are you to making changes in your life right now? *

I’m fully committed and ready to take action.

I’m motivated, but have some reservations.

I want to change, but I’m unsure if I’m ready.

I’m not sure if I’m ready to commit to change.

Our Pre-Assessment Questionnaire​