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First Name
Your answer
Last Name
Your answer
Do you have Blue Tansy on hand to complete the experiment?
Yes
No
Clear selection
What are your top three priorities to get done this month?
Your answer
Do you write a daily 'To Do' list?
Your answer
Rate yourself on a scale of 1-10 of how effective you consider yourself to be at completing tasks or projects. (1 = not good / 10 = excellent)
Not Good
1
2
3
4
5
6
7
8
9
10
Excellent
Clear selection
Do you consider yourself resistant to change?
Your answer
Do you often feel lethargic, drained, apathetic, sluggish, or exhausted?
Your answer
When faced with a challenge in your life do you:
Consider all your options, choose one, and act on it.
Retreat to your bedroom with a bag of chips for a Netflix binge
Cry and call your mama
Clear selection
Would you consider yourself a procrastinator?
Your answer
On a scale of 1 - 10, hoe energized to you feel on a daily basis? (1 = low energy / 10 = highly energetic)
Low Energy
1
2
3
4
5
6
7
8
9
10
Highly energetic
Clear selection
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