Mindset Questionnaire - Rossell Fitness

Name*

First Last

Date*

Email*

We will use your email to send you some follow up information related to the answers in your questionnaire. By filling this form in and submitting the form to us you are giving us your consent to contact you via email.

What do you like about yourself?*

What do you dis-like about yourself?*

What would you say your strengths are? (for example: cooking, nutrition knowledge, mindset, exercise, motivation, compassion etc)*

What would you say your greatest weakness is? (for example: cooking, nutrition knowledge, mindset, exercise, motivation, compassion etc)*

Have you ever used alcohol or food to avoid your feelings? (e.g binge eating or binge drinking?)*

YES - Binge eating
YES - Over eating at meal times / snacks
YES - Binge drinking
YES - Both binge eating and binge drinking
No I have not done either of these things

If YES to the previous question, when was the last time that you did this?*

Do you find it easy to talk about your honest feelings? (ie being vulnerable?)*

Yes
No

How many people can you be yourself with?*

Just my partner
My family
Some close friends
My therapist
No-one at all

How much time do you spend wearing a mask and pretending that you are ok when you are not ok?*

When I am work
When I with friends
When I around strangers
Most of the time
All of the time
None of the time

Describe your body in 3 words*

Have you ever tried to meditate or do breath work?*

Yes I do it as a habit
Yes but I didn't really 'get it'
No but I am curious about it
No I feel resistant to it

Breathwork has amazing benefits for calming down your nervous system and can be great at helping with the management of stress, anxiety and gut issues.

When was the last time that you did something fun where you laughed and felt joyful?*

This week
Last week
Last month
I don't remember feeling joyful recently

Do you consider fun activities and mindset work to be on the same level of importance as exercise, family obligations and work?*

Yes
No
I hadn't considered it until you asked me the question today

Have you been medically diagnosed with stress, anxiety, depression, PTSD or bipolar?*

If you answered OTHER in question 16 please specify below*

If this is not applicable to you please type N/A If you would prefer not to say please type PREFER NOT TO SAY

Please disclose any medications that you are taking for any emotional or psychological conditions?*

for example anti-anxiety meds, antidepressants If you would prefer not to say please type PREFER NOT TO SAY

Please feel free to use the box below to tell us any additional information that is relevant about your story including what led you here today to fill this questionnaire in.....*

If you do not want to share anything here, please type X into the box

Rossell Fitness Mindset Questionnaire