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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
Almost Always (4)
Often (3)
Sometimes (2)
Seldom (1)
Almost Never (0)
2. I have a positive outlook toward life
Almost Always (4)
Often (3)
Sometimes (2)
Seldom (1)
Almost Never (0)
3. I trust that God is working in my life
Almost Always (4)
Often (3)
Sometimes (2)
Seldom (1)
Almost Never (0)
4. My faith is an important priority for me
Almost Always (4)
Often (3)
Sometimes (2)
Seldom (1)
Almost Never (0)
5. I am aware of and grateful for God's creation and people
Almost Always (4)
Often (3)
Sometimes (2)
Seldom (1)
Almost Never (0)
6. I am aware of the rhythm of my day
Almost Always (4)
Often (3)
Sometimes (2)
Seldom (1)
Almost Never (0)
7. I am satisfied with the balance in my life (Spiritual, Physical Health & Relationships)
Almost Always (4)
Often (3)
Sometimes (2)
Seldom (1)
Almost Never (0)
8. I am content with my life
Almost Always (4)
Often (3)
Sometimes (2)
Seldom (1)
Almost Never (0)
9. I am satisfied with my level of energy
Almost Always (4)
Often (3)
Sometimes (2)
Seldom (1)
Almost Never (0)
10. I am satisfied with the way my body functions for daily activities of living
Almost Always (4)
Often (3)
Sometimes (2)
Seldom (1)
Almost Never (0)
11. I am satisfied with my physical health
Almost Always (4)
Often (3)
Sometimes (2)
Seldom (1)
Almost Never (0)
12. I usually wake up feeling rested
Almost Always (4)
Often (3)
Sometimes (2)
Seldom (1)
Almost Never (0)
13. I am able to focus and think clearly
Almost Always (4)
Often (3)
Sometimes (2)
Seldom (1)
Almost Never (0)
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
Almost Always (4)
Often (3)
Sometimes (2)
Seldom (1)
Almost Never (0)
2. I freely receive support from others
Almost Always (4)
Often (3)
Sometimes (2)
Seldom (1)
Almost Never (0)
3. I ask for help when I need it
Almost Always (4)
Often (3)
Sometimes (2)
Seldom (1)
Almost Never (0)
4. I am part of a Christian community that supports me
Almost Always (4)
Often (3)
Sometimes (2)
Seldom (1)
Almost Never (0)
5. I pray for others
Almost Always (4)
Often (3)
Sometimes (2)
Seldom (1)
Almost Never (0)
6. I would like my church to support me in my efforts to care for my body
Almost Always (4)
Often (3)
Sometimes (2)
Seldom (1)
Almost Never (0)
7. My church intentionally supports my efforts to care for my body
Almost Always (4)
Often (3)
Sometimes (2)
Seldom (1)
Almost Never (0)
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
Almost Never (4)
Seldom (3)
Sometimes (2)
Often (1)
Almost Always (0)
2. I feel anxious
Almost Never (4)
Seldom (3)
Sometimes (2)
Often (1)
Almost Always (0)
3. I feel down or depressed
Almost Never (4)
Seldom (3)
Sometimes (2)
Often (1)
Almost Always (0)
4. I feel stressed
Almost Never (4)
Seldom (3)
Sometimes (2)
Often (1)
Almost Always (0)
5. I have difficulty falling asleep
Almost Never (4)
Seldom (3)
Sometimes (2)
Often (1)
Almost Always (0)
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
Almost Always (4)
Often (3)
Sometimes (2)
Seldom (1)
Almost Never (0)
2. I feel confident in my ability to give care and love to others
Almost Always (4)
Often (3)
Sometimes (2)
Seldom (1)
Almost Never (0)
3. I feel confident in my ability to let others give me care and love
Almost Always (4)
Often (3)
Sometimes (2)
Seldom (1)
Almost Never (0)
4. I feel confident that I know which food choices reduce inflammation and improve my health
Almost Always (4)
Often (3)
Sometimes (2)
Seldom (1)
Almost Never (0)
5. I feel confident in my ability to make healthy food choices most of the time
Almost Always (4)
Often (3)
Sometimes (2)
Seldom (1)
Almost Never (0)
6. I feel confident in my ability to be physically active most days
Almost Always (4)
Often (3)
Sometimes (2)
Seldom (1)
Almost Never (0)
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 days
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2 days
3 days
4 days
5 days
6 days
7 days
1. Spend at least 15 minutes alone with God
0 days
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2 days
3 days
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5 days
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7 days
2. Read the Bible
0 days
1 day
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3 days
4 days
5 days
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7 days
3. Pray for myself
0 days
1 day
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3 days
4 days
5 days
6 days
7 days
4. Sense God’s presence
0 days
1 day
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7 days
5. Thank God for something
0 days
1 day
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7 days
6. Pray for others
0 days
1 day
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7 days
7. Support a friend or family member with a personal challenge
0 days
1 day
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7 days
8. Let a friend or family member support me
0 days
1 day
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6 days
7 days
9. Eat at least 7 servings of fruits & vegetables
0 days
1 day
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4 days
5 days
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7 days
10. Eat a healthy breakfast of whole food from nature (not processed food)
0 days
1 day
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5 days
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7 days
11. Eat fish high in Omega 3 oil or take an Omega-3 oil supplement
0 days
1 day
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5 days
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7 days
12. Drink at least 8 glasses of water
0 days
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7 days
13. Move in a way that elevated your heart rate for at least 30 minutes
0 days
1 day
2 days
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4 days
5 days
6 days
7 days
14. Get 8 hours (or more) of sleep at night
0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days
15. Keep track of my daily activities, thoughts, prayers or reflections in a journal
0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days
16. Practice mindful eating (eating slowly & enjoying food without distractions or multi-tasking)
0 days
1 day
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3 days
4 days
5 days
6 days
7 days
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:
*
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)
*
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.)
*
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
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
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
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
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
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
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
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
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
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
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
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?