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Name: Class:
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Self-Care Evaluation
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Based off of a document originally created by MB Creations downloaded for free on teachers pay teachers.
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Directions: Read each statement. Check the one box on how well you practice self-care pertaining to each statement on a 5-1 scale.
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Check 5 if this ALWAYS applies to you.
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Check 4 if this ALMOST ALWAYS applies to you.
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Check 3 if this SOMETIMES applies to you.
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Check 2 if this HARDLY EVER applies to you.
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Check 1 if this NEVER applies to you.
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1. I take time for myself every day.
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2. I make time for spirituality, mindfulness, or religion in any form.
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3. I limit the amount of TV I watch each day
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4. I limit the amount of gaming, Youtube, or internet surfing I do each day.
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5. I exercise at least 5 days a week for 30 minutes
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6. I drink 6-8 glasses of water each day
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7. I get 8-10 hours of sleep every night.
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8. I brush AND floss my teeth.
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9. I practice good hygiene (shower, brush hair, etc.).
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10. I eat approximately 5 fruits and veggies a day.
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11. I limit junk food/fast food consumption.
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12. I generally wear clean clothes.
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13. I get together outside of school with a friend at least once a month and enjoy hobbies.
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14. I have a relaxing routine before bed and a nurturing morning routine.
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15. I usually know what I need and what I am feeling.
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16. My organized environment supports my goals.
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17. I take breaks and have something to look forward to every evening.
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18. I know what I am passionate about.
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Total Score:0
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