Daily Routine Questionnaire Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Date of Birth *Month / Day / Year (time)Location of Birth *City, State or Province, CountryDescribe your current daily routine *Does it vary day to day? Are Mondays special?How satisfied are you with your daily routine? (0 = not satisfied at all ; 7 = extremely satisfied ; 10 = perfectly fulfilled) Selected Value: 0 Is there a time of day when you feel low energy, de-motivated, or sad?Early Morning (waking to 8:00 a.m.)Late Morning (8:00 a.m. to 12:00 p.m.)Afternoon (12:00 p.m. to 4:00 p.m.)Late Afternoon (4:00 p.m. to 5:00 p.m.)Evening (5:00 p.m. to 9:00 p.m.)Late Evening (9:00 p.m. to 12:00 a.m.)Midnight to Early Morning (12:00 a.m. to sunrise)Anxious or restless?Early Morning (waking to 8:00 a.m.)Late Morning (8:00 a.m. to 12:00 p.m.)Afternoon (12:00 p.m. to 4:00 p.m.)Late Afternoon (4:00 p.m. to 5:00 p.m.)Evening (5:00 p.m. to 9:00 p.m.)Late Evening (9:00 p.m. to 12:00 a.m.)Midnight to Early Morning (12:00 a.m. to sunrise)What do you most look forward to? *It can be anything, no matter how seemingly small.What is your biggest challenge in the morning? *Afternoon? *Night? *What is your #1 life goal? *Do you have a short term aspiration?Example: Learn SpanishDescribe ANY insecurities that you may have *Literally anything. Do not hold back!How often do you cook meals? *Examples: three times a day, once a day, twice a day, or five times a week.Do you want to change this in any way? *Example: "I want to start cooking breakfast every morning."Which relationships are most important to you? *Please describe their daily schedule and availability *Are you satisfied with your current balance of for-profit work and philanthropy? *YesNoI'm unsureDo you need time to expand on a skill? *If so, what is the skill?What do you wish you had more time for? *Any answer is valid!What, if anything, has stood between you and your goals? *Religious AffiliationCompletely Optional; you can leave this blank!What are your daily spiritual practices? Do they have to happen at specific times?Please share anything you wish to share about your beliefs and valuesDescribe your responsibilities *Do you pay the bills? Check the mail? Wash dishes? List it all!Do you feel you are keeping up with them well?Heck yes, I am so on top of things!For the most part, yes.I am unsure.Sometimes, but I struggle.Almost never. I am drowning!If so, what has empowered you to thrive in this way?If not, what prevents you from doing this?How much money do you set aside each week for leisure and self-care?OptionalIs there anything about this budget that you need to change? *If so, why?Do you have any limitations or disabilities? (example: chronic pain or PTSD) *If so, please describe what this challenges you inWhat unmovable time blocks do you have? *Examples: weekly doctor visits, picking up the kids from school, a time when medication must be taken, etcPlease describe your break times at work *How long is your lunch? Is it always at the same time?Which days of the week are the most difficult? *Please include whyDid you save a copy of this for your own records? *YesNo, and I understand that I may not be able to access this again.Please save this for your own records!Send to Penny