Questionnaire 5D5W

You will never change your life until you change something you do daily.
The secret of your success is found in your daily routine.

Love Being - 5 Days Off for 5 Weeks

* Indicates required field

Name *

First

Last

Think about your energy levels, stress levels, weight, family life, head-space, work-life etc. and answer the following questions.
Be honest and thorough with your thoughts.

How do you feel today? *

How do you want to feel? *

What are your intentions when considering change to support you goals? *

What kind of support are you looking for? *

Goals

I’d like for you to think about your goals in two parts.
PRIMARY goals - These goals will be challenging, achievable & realistic and above all – IMPORTANT. These are the goals that have made you begin on this 29 day journey. These goals are what your focus is on over the next month and day by day, you will be working towards. These goals will require the building of habits and, the breaking of habits.. Include as many as you like but PLEASE, don’t set yourself up for failure. Be kind and think about what is most important right at this moment.

SECONDARY goals - You may also want to add smaller goals that have been niggling at you for some time. These could be things like de-cluttering your mental head space. Examples could be to clean out your wardrobe, de-clutter the kitchen cupboards/garage or to even start to read, or spend some quality time with your partner or kids.

Define one or two PRIMARY goals. *

Define any SECONDARY goals (optional). *

Habits

Think about habits you want to break or implement in order to achieve your PRIMARY goals.

Habit 1 *

What is your current relationship with this habit? *

What relationship do you want to have with this habit? *

How will you feel if change doesn’t occur? *

How will you feel is change is successful? *

IF trying to break a habit, complete the following:

What will you do with your time instead? What are your options? *

What activities are attached to this habit? (e.g. sleeping, TV time, parties) *

What temptations need to be removed? *

Is there anyone you can rely on to support you through times of temptation? *

IF trying to implement a new habit, complete the following:

What are you giving up for this to happen? *

What barriers may lead you to not following through with your commitment? *

What will motivate you to follow through on your commitment to this change? *

Is there anyone you can rely on to support you through times when you’re feeling unmotivated? *

Habit 2 *