Balance Wheel Gravity Form - Life On Your Terms

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Balance Wheel Assessment Form

Defining Life On Your Terms

Personal Information

Please fill out the following information so that we can personalize your results. *All fields are required

Name(Required)

First Last

Name

Email(Required)

Age(Required)

Please enter a number from 18 to 100.

Gender(Required)

Marital Status(Required)

Health

Describe Your Physical Health

I'm completely satisfied with my physical health.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

Standing in front of a mirror, I'm completely satisfied with my appearance.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I am completely satisfied with the time I invest in my physical health.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I have a healthy relationship with what I eat and drink.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I am confident that the vices I choose to embrace have minimal negative impact on my health.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

Health

Describe your mental health

I'm completely satisfied with my mental health.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

The people I surround myself with have a positive impact on my life.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I rarely have feelings of dread or worry.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I consistently invest quality time for quiet contemplation.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I am completely satisfied with my moral and/or spiritual well-being.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

Health

Describe your spiritual health

I surround myself with others who share my moral and/or spiritual beliefs.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I make important life decisions based on my moral and/or spiritual beliefs.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

My moral and/or spiritual beliefs guide my purpose in life.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

Resources

Talent

I've discovered my true natural talents.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I embrace and utilize my talents to their fullest potential.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I consistently invest time to develop and improve my talents.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

Others recognize and appreciate the talents I possess.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I maximize my talents to create lasting impact.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

Resources

Treasure

I have no desire for additional material possessions.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I can comfortably live without an income for at least six months.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

My financial stability enables me to live the life I desire.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

My material possession enable me to live the life I want to live.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

My finances and/or work are not focused on supporting my material possessions.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

Resources

Time

I have adequate time to comfortably complete all my work and daily tasks.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I am completely satisfied with the flexibility I have to take time off.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I am completely satisfied with the time I invest in my own self-care.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I am completely satisfied with the time I invest to support others.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I am completely satisfied with the time I invest in non-work activities.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

Professional

Job Satisfaction

I am completely satisfied with the work I do.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I am completely satisfied with how much I am challenged with my work.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I have clear expectations at work.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I know when I have been successful at work.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

My work has a significant impact.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

Professional

Compensation

At work, I am compensated fairly for the value I provide.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I have the flexibility to work when and how I want to work.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

My talents are utilized to their highest and best use at work.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I am completely satisfied with my opportunity for growth at work.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I am completely satisfied with my work skills and have the opportunity to grow, if desired.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

Professional

Environment

I am completely satisfied with my physical work space.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I support and respect the people with whom I work.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

The people with whom I work support and respect me.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

The purpose, direction, and goals of my work are clear.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

My workplace values are aligned with my personal values.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

Relationships

Partner

I am completely satisfied with the relationship I have with my significant other.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

My significant other and I have clear goals for our future.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

My significant other and I are completely open, honest, and consistent in our communication.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I understand and support my significant other's dreams and goals.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

My significant other is supportive of my dreams and goals.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

Relationships

Family

I am completely satisfied with the relationship I have with my family.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I am completely satisfied with the level of communication I have with my family.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I am completely satisfied with the level of support I provide my family.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

When conversing with my family, I ask questions and actively listen.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I am completely satisfied with the amount of time I invest with my family.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

Relationships

Friends

I am completely satisfied with the quality of my friendships.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I am completely open, honest, and consistent in my communication with my friends.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I am completely satisfied with the frequency my significant other and I engage with our friends.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

I am completely satisfied with the level of support I provide my friends.(Required)

On a scale of 1 to 5, with 1 meaning "Strongly Disagree" and 5 meaning "Strongly Agree", how much do you agree with this statement?

Please enter a number from 1 to 5.

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Health Total(Required)

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Resources Total(Required)

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Professional Total(Required)

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Relationships Total(Required)

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