Self Discovery Questionnaire

Self Discovery Questionnaire

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  • SOUL SERENITY AND DIVINE WELLNESS RETREAT

    DIVINE SELF QUESTIONNAIRE

  •  -  - Pick a Date
  • Thank you for choosing Soul Serenity & Divine Wellness Retreats to enable and enhance your health and wellbeing.

    The following questionnaire is a tool to create a unique one on one experience, however, Desiree and I will be facillitating the Ri-Zen Soul session together with you.

    There is no need to answer all of the questions, except the following bulleted sections:

    • Lifestyle...Eating Habits, Food Preferences, Excercise
    • Daily Stressors
    • "Rate on a scale of 1-5"...Box that starts with Nutritional Wisdom
    • "Everyone has a mix of learning styles" box
    • Everything else is optional. Whatever you feel would benefit you by Desiree and I knowing more about you...that's what you may want to answer.
    • Please read and sign the Informed Consent (even if you have already done this on another form)

    Just a few thoughts to help you complete this with ease and flow:

    • Find a private space where you will be relaxed away from distractions, including a cell phone
    • BREATHE AND GIVE YOURSELF PERMISSION TO LET GO OF THOUGHTS OF THINGS TO DO!...ETC.
    • Be mindful as you answer the questions on how your body responds. You may feel nothing or you may feel something... If so, where? Are emotions coming up for you? If you feel uneasy, note where in your body you feel it.

    If you need to take a break, do not worry as you will be able to stop and go back to the questions at your convenience.

    If you have any issues completing the questionnaire online. Please send me a text to let me know, and I will respond ASAP... Thank you so much...Desiree and I look forward to assisting you on your healing journey!!!

    Beth @ 954.278.7125

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  • LIFESTYLE

    Check all the factors that apply:
  •   Yes No
    Fast eater
    Erratic eating habit
    Eat to live
    Live to eat
    Late-night eating
    Family contradicts my eating habits
    Rely on fast food
    Negative relationship with food
    Emotional eater
    Time constraint
    Poor snack choices
    Travel frequently
  •   Yes No
    Vegan
    Vegetarian
    Macrobiotic
    Organic
    Raw food
    High protein
    Gluten-free
    Gluten/casein free
    Allergies (list all allergies below)
    Sensitivities (list all sensitivities below)
  • EXERCISE

  •   Type/Intensity (low/mod/high) # Day Per Week Duration (mins)
    Stretching/Yoga
    Cardio/Aerobics
    Strength Training
    Sports or Leisure
    Dancing
    Walking
    Other
  •   TRUE FALSE MAYBE SO
    I don't have to see healing to believe it exists
    I can alter my genes by how I think
    My body has the innate ability to heal itself
    My body responds to my emotions~when they change, so does my body
    I have healed myself at least once
    I've used herbal and/or aromatherapy remedies that were effective
    My thoughts and speech are more positive than negative
    Everything happens for a reason
    I care what others think about me
    I would most likely speak up vs. going along with the crowd
    I have the tendency to procrastinate or give up on things
    I feel confident in trusting my intuition
    I am conscious of living in the present most of the time
    I live mostly in the past or the future
    I am judgemental and/or critical
    I feel that I am truly blessed
    I easily forgive others
    I easily forgive myself
    I don't hold grudges
    I believe in miracles
    I am the creator of my own reality
    Gratitude creates positive change in my life
    Do I believe in Angels, Guides and Masters
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