Current and Desired States Form

Please take a little time to contemplate your answers on the following questions. This gives us a snapshot of where you are in the coaching process in each of these areas. There are nine sections below, each representing a section of the Duke Wheel of Health which defines true health based on these nine factors. To see an image of the Wheel, click HERE or to read a more detailed description of the nine segments, click HERE. Please complete and submit this form at least 48 hours prior to our session.

Name

Email

Date

1-Mindful Awareness: Awareness of the present moment, paying attention to what you are doing while you are doing it. CURRENT STATE: How would you rate this area of your life currently (1=low, 10=high)? Click the drop down box to select a number.

Briefly describe the reasons you chose this rating above.

DESIRED STATE: What would be an improvement, enhancement or change you could make? What would make this area a 10 for you?

2-Movement, Exercise and Rest: Activities of daily living like cleaning and gardening as well as dancing, yoga, walking, running, cycling balanced with adequate rest and relaxation. CURRENT STATE: How would you rate this area of your life currently (1=low, 10=high)? Click the drop down box to select a number.

Briefly describe the reasons you chose this rating above.

DESIRED STATE: What would be an improvement, enhancement or change you could make? What would make this area a 10 for you?

3-Nutrition: Eating a balanced, healthy diet, taking time to prepare food that nourishes you. CURRENT STATE: How would you rate this area of your life currently (1=low, 10=high)? Click the drop down box to select a number.

Briefly describe the reasons you chose this rating above.

DESIRED STATE: What would be an improvement, enhancement or change you could make? What would make this area a 10 for you?

4-Physical Environment: Spaces where you live/work (lighting, noise, toxins, color) as well as landscapes surrounding those spaces. CURRENT STATE: How would you rate this area of your life currently (1=low, 10=high)? Click the drop down box to select a number.

Briefly describe the reasons you chose this rating above.

DESIRED STATE: What would be an improvement, enhancement or change you could make? What would make this area a 10 for you?

5-Relationships and Communication: Spending time with family, friends and/or coworkers who are supportive, and with whom you communicate effectively. CURRENT STATE: How would you rate this area of your life currently (1=low, 10=high)? Click the drop down box to select a number.

Briefly describe the reasons you chose this rating above.

DESIRED STATE: What would be an improvement, enhancement or change you could make? What would make this area a 10 for you?

6-Spirituality: Seeing purpose and meaning in something larger than one's self; may include religious affiliation or other areas such as nature or the arts.

Briefly describe the reasons you chose this rating above.

DESIRED STATE: What would be an improvement, enhancement or change you could make? What would make this area a 10 for you?

7-Personal and Professional Development: Growing and developing one's own abilities, talents and interests, both in 'being' and 'doing,' and living with both in balance. CURRENT STATE: How would you rate this area of your life currently (1=low, 10=high)? Click the drop down box to select a number.

Briefly describe the reasons you chose this rating above.

DESIRED STATE: What would be an improvement, enhancement or change you could make? What would make this area a 10 for you?

8-Mind-Body Connection: Paying attention to the interconnectedness of the mind and the body, and the effects they have on each other. Using techniques such as breathing practices, meditation, progressive muscle relaxation or guided imagery to activate the body's relaxation and healing response. CURRENT STATE: How would you rate this area of your life currently (1=low, 10=high)? Click the drop down box to select a number.

Briefly describe the reasons you chose this rating above.

DESIRED STATE: What would be an improvement, enhancement or change you could make? What would make this area a 10 for you?

9-Professional Care for both Prevention and Intervention using both Conventional and Complementary Approaches: Routine screenings, following treatments recommended by your team of health professionals.

Briefly describe the reasons you chose this rating above.

DESIRED STATE: What would be an improvement, enhancement or change you could make? What would make this area a 10 for you?

After you submit this form, a copy of what you submitted will come onto the screen. Click HERE to return to the Coaching Paperwork page.