Daily Habits & Attitudes

Before you begin the Come Alive! Small Group Program, please complete the following Come Alive! Daily Habits & Attitudes Pre-Program Assessment.  
We ask you to thoughtfully and honestly consider your answers.
Your assessment responses will uniquely represent you at this point in time. (There’s no need to compare your results with others.) After submitting the test, please print a copy of the results for you to keep.
At the end of the Come Alive! program, you will be given directons by your facilitator to complete the Come Alive! Daily Habits & Attitudes Post-Assessment. After taking the post assessment, you can
compare your responses to each question in the Pre-Asseement to the Post-Assessment. Comparing your answers will help you understand how your daily rhythms, attitudes, and habits are changing.
* First name
* Last name
* Email address
Phone number (optional)
* City
* State
Small Group Name (optional)
* How I Look at Things
Check the box that most closely describes how you feel most of the time
Almost Always (4)Often (3)Sometimes (2)Seldom (1)Almost Never (0)
1. I feel my life has purpose and value
2. I have a positive outlook toward life
3. I trust that God is working in my life
4. My faith is an important priority for me
5. I am aware of and grateful for God's creation and people
6. I am aware of the rhythm of my day
7. I am satisfied with the balance in my life (Spiritual, Physical Health & Relationships)
8. I am content with my life
9. I am satisfied with my level of energy
10. I am satisfied with the way my body functions for daily activities of living
11. I am satisfied with my physical health
12. I usually wake up feeling rested
13. I am able to focus and think clearly
If you'd like to know your score in the How I Look  At Things category, add the Numeric Values of Questions 1-13 and enter the subtotal here:
* My Relationship With Others
Check the box that most closely describes how you feel most of the time
Almost Always (4)Often (3)Sometimes (2)Seldom (1)Almost Never (0)
1. I listen and respond to others with understanding
2. I freely receive support from others
3. I ask for help when I need it
4. I am part of a Christian community that supports me
5. I pray for others
6. I would like my church to support me in my efforts to care for my body
7. My church intentionally supports my efforts to care for my body
If you'd like to know your score in the My Relationship With Others category, add the Numeric Values from Questions 1-7 and enter the subtotal here:
* What I've Noticed Lately
PLEASE NOTE! THE ANSWER WORDING & VALUES FOR THIS SECTION ARE REVERSED
 
Almost Never (4)Seldom (3)Sometimes (2)Often (1)Almost Always (0)
1. I have too much to do and I am pressed for time
2. I feel anxious
3. I feel down or depressed
4. I feel stressed
5. I have difficulty falling asleep
If you'd like to know your score in the What I've Noticed Lately category, add the numeric values from questions 1-5 and enter the subtotal here:
* My Level of Confidence
PLEASE NOTE!  THE CHANGE IN ANSWER WORDING & VALUES IN THIS SECTION
Almost Always (4)Often (3)Sometimes (2)Seldom (1)Almost Never (0)
1. I feel confident in my ability to seek God first as I live my life
2. I feel confident in my ability to give care and love to others
3. I feel confident in my ability to let others give me care and love
4. I feel confident that I know which food choices reduce inflammation and improve my health
5. I feel confident in my ability to make healthy food choices most of the time
6. I feel confident in my ability to be physically active most days
If you'd like to know your score in My Level of Confidence category, add the numeric values from questions 1-6 and enter the subtotal here: 
* My Daily Rhythm
On how many of the past 7 days did you...
0 days1 day2 days3 days4 days5 days6 days7 days
1. Spend at least 15 minutes alone with God
2. Read the Bible
3. Pray for myself
4. Sense God’s presence
5. Thank God for something
6. Pray for others
7. Support a friend or family member with a personal challenge
8. Let a friend or family member support me
9. Eat at least 7 servings of fruits & vegetables
10. Eat a healthy breakfast of whole food from nature (not processed food)
11. Eat fish high in Omega 3 oil or take an Omega-3 oil supplement
12. Drink at least 8 glasses of water
13. Move in a way that elevated your heart rate for at least 30 minutes
14. Get 8 hours (or more) of sleep at night
15. Keep track of my daily activities, thoughts, prayers or reflections in a journal
16. Practice mindful eating (eating slowly & enjoying food without distractions or multi-tasking)
If you'd like to know your score in the My Daily Rhythm category, add the numeric values and enter the subtotal here:
Add the 5 subtotals from each category and enter the grand total here:
(Yes, we realize that we are making you work your math muscles today - thank you in advance for your effort!)

A Few of My Physical Measurements:
Enter only numbers in the boxes.
Example: 5 foot tall would be:  In Feet: 5 and In Inches: 0


Height: 
* In Feet:
* In Inches:
* Weight (In Pounds):
* Waist Circumference (In Inches):
Most Recent Blood Presssure Measurement: (if you don't know your blood pressure, you may skip this question)
Systolic (top number)
Diastolic (bottom number)
* Is your Blood Pressure at or below the average healthy blood pressure of 120/80?
* Do you currently smoke cigarettes, cigars, pipes or use chewing tobacco?
My Goals:

What are your top 3 goals for the Come Alive! program & why? (Please be as specific as possible.)
* 1.
* 2.
* 3.
* Are there any barriers you believe may hold you back from reaching your goals?  Please describe.
* Rank the 11 topics below in order of importance to you (click hold and drag your most important topic from the left box into the right box, then repeat with topic #2 and so on.
You may change the order of the topics in the right box by click hold and dragging them up or down in the right box)
    • Strengthen my relationship with God
    • Learn what the Bible says about physical health
    • Improve my relationships with others
    • Make new friends
    • Have fun
    • Learn more about myself
    • Increase my energy level
    • Lose weight
    • Create healthy habits to improve my health
    • Learn how to move more
    • Manage a chronic health condition or disease


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    Strengthen my relationship with God
    Learn what the Bible says about physical health
    Improve my relationships with others
    Make new friends
    Have fun
    Learn more about myself
    Increase my energy level
    Lose weight
    Create healthy habits to improve my health
    Learn how to move more
    Manage a chronic health condition or disease
    Please tell us about yourself:
    * What is your gender?
    * In what range does your age fall?
    * Which of the following best describes your ethnicity?
    * What category best describes you?
    * What is the highest level of education you have completed?
    * How many children do you have under the age of 18 and living in your household?