Self-Assessment Questionnaire
Instructions:
Rate yourself on a scale from 1 to 10, where 1 is the lowest and 10 is the highest. For each section, provide comments or reflections where applicable.
Engagement and Alignment
Engagement in Work:
On a scale of 1 to 10, how fully engaged are you in your work?
Score: ___
What's standing in your way? (Comment)
Behavior and Values Alignment:
How closely does your everyday behavior match your values and serve your mission?
Score: ___
Where are the disconnects? (Comment)
Embodiment of Values and Vision:
How fully are you embodying your values and vision for yourself at work, at home, in your community?
Score: ___
Where are you falling short? (Comment)
Habits and Emotional Consistency
Habits Alignment:
How well do your habits of nutrition, exercise, sleep, and the balance of stress and recovery serve your key values?
Score: ___
Comments: (Optional)
Emotional Consistency:
How consistent is your emotional response in any given situation with your values?
Score: ___
Is it different at work than at home? If so, how? (Comment)
Prioritization and Attention:
To what degree do you establish clear priorities and sustain attention on tasks?
Score: ___
How consistent are those priorities with what you say is most important to you? (Comment)
Energy Management
Energy Management Relative to Values:
How well do you manage your energy relative to what you say matters most?
Score: ___
Comments: (Optional)
Impact of Habits on Energy:
How do your habits of sleeping, eating, and exercise affect your available energy?
Score: ___
Comments: (Optional)
Negative vs. Positive Energy Investment:
How much negative energy do you invest in defense spending, frustration, anger, fear, resentment, and envy, as opposed to positive energy utilized in the service of growth and productivity?
Score: ___
Comments: (Optional)
Energy Balance Between Self and Others:
How much energy do you invest in yourself versus in others?
Score: ___
How comfortable are you with that balance? (Comment)
How do those closest to you feel about the balance you've struck? (Comment)
Energy Spent on External Events:
How much energy do you spend worrying about, feeling frustrated by, and trying to influence events beyond your control?
Score: ___
Comments: (Optional)
Wise and Productive Energy Investment:
How wisely and productively are you investing your energy?
Score: ___
Comments: (Optional)
COMMON PERFORMANCE BARRIERS
Low energy
Lack of trust in others
Impatience
Lack of integrity
Defensiveness
Indecisive
Negative attitude
Poor communication skills
Critical of others
Poor listening skills
Low stress tolerance
Lack of passion
Moody/irritable
Low self-confidence
Poor team player
Lack of empathy
Inflexible/rigid
Overly dependent
Unfocused
Poor work-life balance
High anxiety
Negative/pessimistic thinking
Poor time management