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M.T.I.

MICHAEL T. INGRAM, M.D.

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Self-Assessments

ADHD

ANXIETY

DEPRESSION

BIPOLAR DISORDER

OCD

SELF-CARE

SELF-CARE ASSESSMENT

Self-care activities are the things you do to maintain good health and improve well-being. Many of these activities you do already as part of your normal routine.

In this assessment you will think about how frequently, or how well, you are performing different self-care activities. This will help you learn about your self-care needs by spotting patterns and recognizing areas of your life that need more attention. Some of these items may not apply to you.

When completing this assessment, use the following rubric:

(1) I do this poorly; I do this rarely
(2) I do this alright; I do this sometimes
(3) I do this well; I do this often
(0) I would like to improve at this; I would like to do this more frequently

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SELF-CARE ASSESSMENT

Your responses WILL NOT be recorded and will be sent to your email only!

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Eat Healthy Foods

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Take care of personal hygiene

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Exercise

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Consistent meals

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Participate in fun activities (e.g., walking, swimming, dancing, sports)

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Adequate sleep

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Regular doctor visits

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Regular dental checkups

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Rest when sick

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Overall Physical Self-Care

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Take time off work, school, and other obligations

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Participate in hobbies

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Get away from distractions (e.g., phone, email)

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Learn new things (away from school or work)

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Express my feelings through talking, art, journaling

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Recognize my own strength and achievements

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Express my feelings through talking, art, journaling

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Go on vacations or daytrips

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Do something comforting (e.g., re-watch a movie, take a bath)

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Express my feelings through talking, art, journaling

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Find reasons to laugh

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Overall Psychological and Emotional Self-Care

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Spend time with people I like

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Call or reach out to friends and family who are far away

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Have stimulating conversations

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Meet new people

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Spend time alone with my romantic partner

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Ask others for help, when needed

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Intimate time with my romantic partner

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Keep in touch with old friends

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Spend time in nature

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Meditate

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Pray

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Recognize the things that give meaning to my life

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Act in accordance with my morals and values

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Participate in a cause that is important to me

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Set aside time for thought and reflection

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Overall Social and Spiritual Self-Care

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Take breaks during work/studying

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Say “no” to excessive new responsibilities

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Take on projects that are interesting or rewarding

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Learn new things related to my profession

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Keep a comfortable workspace

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Maintain balance between my professional and personal life

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

Overall Professional/School Self-Care

I do this poorly; I do this rarely I do this alright; I do this sometimes I do this well; I do this often I would like to improve at this; I would like to do this more frequently

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