Source Medicine Wellbeing Questionnaire
This form is about your overall wellbeing and experience of life.
Please scale the items 0 - 10 where 0 means none and 10 is optimal.
The information is used to assess your progress and also (with no personal details) for Source Medicine research. At the end of the form you can request a copy for your own reference.
Email address *
Full name of person using the resonance (or initials and date of birth) *
This is used as a reference, to link feedback.
Your answer
Practitioner name (if relevant)
Your answer
1. Overall physical wellbeing
Low
High
2. Energy
Low
High
3. Memory and mental alertness
Low
High
4. Emotional wellbeing
Low
High
5. Sense of connection with inner self and emotions
Low
High
6. Happiness, smiles and laughter
Low
High
7. Creative expression and play (expressing yourself in ways that inspire you)
Low
High
8. Ability to initiate and complete tasks - getting things done
Low
High
9. Sense of connection with your sexuality (if age appropriate)
Low
High
10. Quality of family relationships
Low
High
11. Quality of connection with others outside close family
Low
High
12. Sense of openness to abundance and wealth
Low
High
13. Sense of fulfillment in life
Low
High
If addressing health issues, please list up to three main symptoms and scale these 0 - 10 where ten is very severe symptoms and zero is completely resolved.
Your answer
Describe Symptom 1:
Your answer
Scale Symptom 1.
Completely resolved
Very severe
Describe Symptom 2:
Your answer
Scale Symptom 2:
Completely resolved
Very severe
Describe Symptom 3:
Your answer
Scale Symptom 3:
Completely resolved
Very severe
For life change and enhancement, please list up to three main issues you are working with and scale these 0 - 10 to indicate where you are with these issues now. For this scaling, ten is all that you could dreamed of and zero is none.
For example: joy; presence; being inspired in your work; life opportunities opening up.
Your answer
Describe Issue 1:
Your answer
Scale Issue 1:
None
All that you dreamed of
Describe Issue 2:
Your answer
Scale Issue 2:
None
All that you dreamed of
Describe Issue 3:
Your answer
Scale Issue 3:
None
All that you dreamed of
Thank you. Is there anything else that you would like to add?
Your answer
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