Burn Out Assessment Tool

Full Name *

First Name Last Name

Email *

example@example.com

How often do you experienced the following?

Physical *

	Daily	3-5 days a week	1-2 days a week	1-2 times per month	Rarely	Never
Fatigue that does not go away without rest
Headaches
Joint Pain
Low back pain
Insomnia, difficulty getting to sleep and/or staying asleep
Tight shoulders, neck or upper back pain
Jaw Pain

Emotional *

	Daily	3-5 days a week	1-2 days a week	1-2 times per month	Rarely	Never
Uncontrolled or sensitive emotions like crying or loss of temper
Crying at inappropriate times
Pessimism, loss of excitement in things you once enjoyed
Feelings of abandonment, or feeling all on your own
Intense emotions such as fear, grief or sadness
Feeling moody and reacting to others in ways you feel you shouldn't
Feel like everything around you is "heavy" and weighing on your shoulders
You feel like walking away from your job or career without your next step planned or available.

Mental *

	Daily	3-5 days a week	1-2 days a week	1-2 times per month	Rarely	Never
Feeling on edge or anxious
Feeling scattered
Overwhelmed by everyday situations or events, like reaction to opening emails
Unable to shut your mind off, especially at night
Difficulty calming your nerves
Difficulty making decisions as easily as you used to
Unable to solve problems as easily as you used to

Memory *

	Daily	3-5 days a week	1-2 days a week	1-2 times per month	Rarely	Never
Concerned you are forgetting or will forget something important
Forgetting simple words or phrases that are familiar to you
Missing important appointments or dates such s Birthdays, anniversaries, etc.
Frequent thoughts of painful past events

Intuition *

	Daily	3-5 days a week	1-2 days a week	1-2 times per month	Rarely	Never
Difficulty translating the guidance your highest self is providing
Difficulty recognizing or acting on intuition when it comes
Difficulty remembering your dreams
Difficulty understanding the meaning and guidance provided in our dreams
Difficulty prioritizing things in life

Spirituality *

	Daily	3-5 days a week	1-2 days a week	1-2 times per month	Rarely	Never
Feeling disconnected from the Divine
Feeling alone on your journey through life
Disconnected from your heart and inner wisdom
Cut off from the deeper truths you know are within you
Easily thrown off by the emotions, thoughts and energies of others

Groundedness (connection to Mother Earth) *

	Daily	3-5 days a week	1-2 days a week	1-2 times per month	Rarely	Never
Feeling uncertain about your future or purpose in this lifetime
Standing at a crossroads in life and need help finding your way
Feeling disconnected from Earth and would like to have a better connection with it.
Difficulty releasing unwanted energies, feeling like things are sticking to you.

Score

Your score indicates a extreme level of stress and serious burnout. It's recommended that you address these changes immediately and make significant changes in your life. These changes include: a thorough physical examination, councelling, coaching, exercise, nutritional changes and a comprehensive and urgent energy medicine package.

You are experiencing high levels of stress and significant burnout and its time to seriously consider major changes in our life. It's recommended to pursue: a thorough physical examination, coaching, exercise, nutritional changes and thorough and immediate energy medicine package.

While you're yet in full-fledge burnout, you could be well on your way. Its recommended to pursue: a physical examination, coaching, and a monthly energy medicine package.

While you may have occasional stressors and minor burnout, your symptoms probably comes and goes when under a tight deadline or challenging expectations. You could benefit from a quarterly coaching and a monthy energy medicine package.