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Life Coaching Questionnaire

The definition of thinking out of the box “ Thinking that frees itself of reflexive obedience to familiar signals”. “The “box” is the result of programming and conditioning self-created in adulthood”.
Dr. David Krueger, M.D.

PLEASE NOTE: Please answer only yes or no to each question. If you think your answer is mostly no answer no if it is mostly yes, answer yes… Thank You

QUESTIONNAIRE

Please note that all fields followed by an asterisk must be filled in.

Name:*
Name:*

E-mail Address*
E-mail Address*

City

Home Phone

When given a compliment do you Shy away, deflect or “deny” it? i.e. “Oh no I don’t…”*
When given a compliment do you Shy away, deflect or “deny” it? i.e. “Oh no I don’t…”*

	Yes
	No

Do you exercise less than 3 times per week? (At least 1 hour continuous exercise time)*
Do you exercise less than 3 times per week? (At least 1 hour continuous exercise time)*

	Yes
	No

Do you find yourself skipping meals throughout the day?*
Do you find yourself skipping meals throughout the day?*

	Yes
	No

Do you get uncomfortable and frustrated doing the same things and getting the same limited results?*
Do you get uncomfortable and frustrated doing the same things and getting the same limited results?*

	Yes
	No

Do you deny your wants or needs to avoid conflict, to please others or to take care of others?*
Do you deny your wants or needs to avoid conflict, to please others or to take care of others?*

	Yes
	No

When you are being confronted or confronting someone, do you have a hard time expressing your emotions?*
When you are being confronted or confronting someone, do you have a hard time expressing your emotions?*

	Yes
	No

Are you easily distracted or find it difficult to focus at work or at home?*
Are you easily distracted or find it difficult to focus at work or at home?*

	Yes
	No

Do you worry about future events that may or may not happen?*
Do you worry about future events that may or may not happen?*

	Yes
	No

Are you usually late for meetings or social gatherings?*
Are you usually late for meetings or social gatherings?*

	Yes
	No

Do you do anything to nurture yourself and reduce stress?*
Do you do anything to nurture yourself and reduce stress?*

	Yes
	No

Do you have a clear internal ideal of who and what you want to be?*
Do you have a clear internal ideal of who and what you want to be?*

	Yes
	No

Do you feel “less than” rather than “equal to” your partner, spouse or friends?*
Do you feel “less than” rather than “equal to” your partner, spouse or friends?*

	Yes
	No

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