Workplace Mindfulness Evaluation Form
* Required
Personal code
*
Your answer
Mindfulness helps get rid of disturbing thoughts and emotions.
*
1 - Strongly Agree
2 - Agree
3 - Neither Agree, nor Disagree
4 - Disagree
5 - Strongly Disagree
0 - Don't Know
I am keen on multitasking, as it allows me to accomplish a lot of tasks.
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1 - Strongly Agree
2 - Agree
3 - Neither Agree, nor Disagree
4 - Disagree
5 - Strongly Disagree
0 - Don't Know
I am unaware of the ways that I am impulsive.
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1 - Strongly Agree
2 - Agree
3 - Neither Agree, nor Disagree
4 - Disagree
5 - Strongly Disagree
0 - Don't Know
When I do something that doesn’t meet my expectations, I give myself a hard time.
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1 - Strongly Agree
2 - Agree
3 - Neither Agree, nor Disagree
4 - Disagree
5 - Strongly Disagree
0 - Don't Know
I am easily distracted.
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1 - Strongly Agree
2 - Agree
3 - Neither Agree, nor Disagree
4 - Disagree
5 - Strongly Disagree
0 - Don't Know
I have problems dealing with stressful situations.
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1 - Strongly Agree
2 - Agree
3 - Neither Agree, nor Disagree
4 - Disagree
5 - Strongly Disagree
0 - Don't Know
I find that I am uncomfortable being around people who need help.
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1 - Strongly Agree
2 - Agree
3 - Neither Agree, nor Disagree
4 - Disagree
5 - Strongly Disagree
0 - Don't Know
When someone is talking, I have trouble putting my own thoughts aside and giving them my full attention.
*
1 - Strongly Agree
2 - Agree
3 - Neither Agree, nor Disagree
4 - Disagree
5 - Strongly Disagree
0 - Don't Know
When I’m concerned about something, it doesn’t occur to me that my thoughts might not be true.
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1 - Strongly Agree
2 - Agree
3 - Neither Agree, nor Disagree
4 - Disagree
5 - Strongly Disagree
0 - Don't Know
I am often preoccupied, and miss what is going on around me.
*
1 - Strongly Agree
2 - Agree
3 - Neither Agree, nor Disagree
4 - Disagree
5 - Strongly Disagree
0 - Don't Know
When my thoughts overtake me and I feel worried, I don’t know how to pause or interrupt this pattern.
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1 - Strongly Agree
2 - Agree
3 - Neither Agree, nor Disagree
4 - Disagree
5 - Strongly Disagree
0 - Don't Know
I can’t imagine getting through a day without my cell phone.
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1 - Strongly Agree
2 - Agree
3 - Neither Agree, nor Disagree
4 - Disagree
5 - Strongly Disagree
0 - Don't Know
After I “send” an important e-mail or text, I often regret what I wrote.
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1 - Strongly Agree
2 - Agree
3 - Neither Agree, nor Disagree
4 - Disagree
5 - Strongly Disagree
0 - Don't Know
When I have difficult thoughts or feelings, I tend to avoid facing them for as long as I can.
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1 - Strongly Agree
2 - Agree
3 - Neither Agree, nor Disagree
4 - Disagree
5 - Strongly Disagree
0 - Don't Know
When I’m working on something, it’s difficult to differentiate between priorities and tasks that could be done later.
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1 - Strongly Agree
2 - Agree
3 - Neither Agree, nor Disagree
4 - Disagree
5 - Strongly Disagree
0 - Don't Know
I tend to have a lot of ideas that never get implemented, and I don’t know what to do about this.
*
1 - Strongly Agree
2 - Agree
3 - Neither Agree, nor Disagree
4 - Disagree
5 - Strongly Disagree
0 - Don't Know
© Dr. Martha Traverso-Yepez and Andrew Safer 2016
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