Fields marked with an * are required

In order to prepare for our meeting - which will be strictly confidential - it would be very helpful if you would consider the following.  It is important to be very honest in your answers since you will receive a report including recommendations specific to your situation which will improve your energy, health and stress-resilience.

It is tempting to give your answers based on what you aim to achieve but this is not helpful.  It is what actually happens most of the time which informs the process and recommendations most useful to you.

If, on pressing send, the form does not clear, please make sure that you have completed all the required sections and resubmit.

    To what extent do you consider the following to be true for you most of the time? In the box, mark statements out of 10, with 0 indicating it isn't true for you at all, and 10 indicating it is completely true.

    The demands placed upon me at work are reasonable and achievable*
    012345678910

    I decide for myself how I do my job and how I plan my day*
    012345678910

    I have the support and resources I need to achieve my goals*
    012345678910

    My working relationships are positive, supportive and fruitful*
    012345678910

    I am clear about my role, expectations of me and how my performance is measured*
    012345678910

    I am comfortable with the rate of and reason for changes which happen*
    012345678910

    I am able to keep my work stress at work and my home stress at home*
    012345678910

    I feel secure and confident in my job*
    012345678910

    My relationships at home are positive, supportive and enjoyable*
    012345678910

    Are you happy with the level of worklife balance you have at the moment?*
    012345678910

    What do you eat in a typical day. Not what you aspire to, but what you actually do eat. Please include approximate times of eating, snacks and what you drink, including beverages, water, soft drinks and alcohol. If your days vary wildly, then please write down a typical 7 days (feel free to do so on a separate document). If your answers are vague, that will mean that we take more time in the session to ascertain the details which will give less time for other work. For a Word template with an example to follow, please contact me. Otherwise, please note that pressing return will take you out of the textbox an you will need to go back into the textbox to continue writing.

    Please mark the following out of 10. 0 indicates no problem at all, 10 indicates that it is a severe problem for you.

    Fatigue*
    012345678910

    Hyperactivity*
    012345678910

    Lethargy*
    012345678910

    Problems sleeping and/or waking up tired*
    012345678910

    Epilepsy*
    012345678910

    Headaches*
    012345678910

    Migraines*
    012345678910

    Irritability*
    012345678910

    Difficulty concentrating*
    012345678910

    Brain Fog*
    012345678910

    Low mood / depressed mood / mood swings*
    012345678910

    Skin problems*
    012345678910

    Indigestion*
    012345678910

    Constipation*
    012345678910

    Diarrhoea*
    012345678910

    Wind*
    012345678910

    Bloating*
    012345678910

    Belching*
    012345678910

    Ulcers*
    012345678910

    High/low blood pressure*
    012345678910Don't know

    High cholesterol*
    012345678910Don't know

    Palpitations*
    012345678910

    Heart condition*
    012345678910

    Breathlessness*
    012345678910

    Asthma*
    012345678910

    Hay fever*
    012345678910

    Allergies*
    012345678910

    Chronic cough*
    012345678910

    Frequent colds*
    012345678910

    Dizziness*
    012345678910

    Type 1 Diabetes*
    012345678910

    Type 2 Diabetes*
    012345678910

    Thank you for your time. This will enable me to make sure that I make the right recommendations for you. If you have any questions prior to meeting with me, do feel free to contact me on 0845 130 0854 or tricia@triciawoolfrey.com.