First Name:

Date:

Time (optional):

Please rank how true these statements are for you since your last report (10 being the highest):

I am forgiving with myself

1  2  3  4  5  6  7  8  9  10

I like how I look

1  2  3  4  5  6  7  8  9  10

I really *feel* my feelings, noticing, without judgement, how they show up in my body

1  2  3  4  5  6  7  8  9  10

I am relaxed about what I eat

1  2  3  4  5  6  7  8  9  10

I enjoy exercise

1  2  3  4  5  6  7  8  9  10

It is of no concern to me whatsoever what others think of me

1  2  3  4  5  6  7  8  9  10

I tend to eat foods that are nourishing and balancing for me

1  2  3  4  5  6  7  8  9  10

I speak my truth

1  2  3  4  5  6  7  8  9  10

I am the "real me" around family, friends, colleagues and strangers

1  2  3  4  5  6  7  8  9  10

I enjoy how my body feels

1  2  3  4  5  6  7  8  9  10

I enjoy being creative/positive/fun with my appearance

1  2  3  4  5  6  7  8  9  10

I enjoy being creative/positive/fun with how I share my body

1  2  3  4  5  6  7  8  9  10

I speak to myself like I am a wondrous, precious being, perfect in my growth and learning

1  2  3  4  5  6  7  8  9  10

I enjoy having structures that support my health (e.g. early bedtimes, exercise routines, healthy eating, healthy self-talk, not just do you do them, but do you enjoy them?!)

1  2  3  4  5  6  7  8  9  10

I am perfect exactly how I am, and exactly how I am changing

1  2  3  4  5  6  7  8  9  10

Comments/Successes/Growth Areas:

Before you go!  Send a "smile" to your body, your organs, and your approximately 100 trillion cells!  They are doing a wonderful job of supporting you and you appreciate them very much!  

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