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SELF AWARENESS QUESTIONNAIRE FOR ABUNDANT HEALTH AND HEALING Henry Grayson, Ph.D.

Remember to be honest with yourself. If not, you are likely to prolong or keep your symptoms unnecessarily, or be more prone to additional ill health in the future. Be sure to allow irrational

answers as well as rational ones. Do not be critical of yourself over any answer you have. Just consider all answers as opportunities to find more abundant health. NOTE: if you start to experience self blame or feel guilt at any point while taking this questionnaire, that may be one of the most important things for you to release, since guilt is a major contributor to getting sick. NAME_________________________________________ DATE: ___________ Since we are dealing, not with a separate mind and separate body, but rather a mindbody, as you answer, think of health or sickness as including both mind and body dimensions. 1. Are you healthy as you would like to be now? ___ All the time ____Most of the time ____Occasionally___ Seldom____ Never 2. What would be excellent health for you? ______________________________ ___________________________________________________________________ ___________________________________________________________________ 3. What would you gain by being in excellent health? _____________________ ___________________________________________________________________ ___________________________________________________________________ 4. What would you lose by being in excellent health? ______________________ ___________________________________________________________________ ___________________________________________________________________ 5. What do you lose by being sick? _____________________________________ ___________________________________________________________________ ___________________________________________________________________ 6. What do you gain by being sick? (Here is a place to allow irrational answers) ___________________________________________________________________ ___________________________________________________________________ 7. What would having excellent health cost you? __________________________ ____________________________________________________________________ ____________________________________________________________________ 8. What does being sick cost you? _______________________________________ ____________________________________________________________________ 9. What does your health threaten? _____________________________________ ____________________________________________________________________ ____________________________________________________________________ 10. Do you believe that sickness is inevitable for you _____ yes ______no 11. Do you want to be well? Circle One: 1 2 3 4 5 6 7 8 9 10 12. What would it take to be well? __________________________________

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________________________________________________________________ ________________________________________________________________ 13. How much of that are you willing to do– so that nothing will stop you? ______________________________________________________________ ______________________________________________________________ 14. What do you believe causes most of your illnesses? _______________ _____________________________________________________________ 15. What is the first thing you think when someone close to you gets sick? ______________________________________________________________ ______________________________________________________________ 16. Who is in charge of your life? _________________________________ ______________________________________________________________ 17. Who or what seems to be in charge of your body? ________________ ______________________________________________________________ ______________________________________________________________ 18. Do you control your body or does it seem like your body and its symptoms control you? _______________________________________________________ __________________________________________________________________ 19. Who and what do you believe you are? _____________________________ __________________________________________________________________ 20. How does that fit with your being sick? _____________________________ __________________________________________________________________ 21. What is the first thing you think when you start to get sick? ____________ __________________________________________________________________ 22. What is the second thing you think? ________________________________ __________________________________________________________________ 23. When I get depressed: ____ (a) look for an external reason ____ (b) I look for the thoughts I have been thinking ____ c) I look for someone or something to blame ____ (d) I blame my body chemistry ____ (e) Other _____________________________________________________ 24. When and in what ways did your primary caretakers take care of you as a child? _______________________________________________________________________ _______________________________________________________________________ 25. What are the ways you missed being taken care of? ________________________ _______________________________________________________________________ 26. Do you remember ever being dependent or vulnerable and showing it? _______ _______________________________________________________________________ 27. What happened when you expressed your dependency or vulnerability? ______ _______________________________________________________________________ 28. Do you feel like you always have to be strong to be in control? _______________ _______________________________________________________________________

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29. What do you gain by being sick? ________________________________________ _______________________________________________________________________

30. If I were well, I would _________________________________________________ _______________________________________________________________________

31. I don’t want to do this (above answer) because ____________________________ _______________________________________________________________________

32. I think that most illnesses happen to us ____ yes ____ no 33. I trust that I have the power to heal ___ yes ____ no 34. I blame others when they get sick ____ yes ____ no 35. I feel guilty when I get sick ____yes ____ no 36. What is the most common approach you take to get well? _________________ _____________________________________________________________________

37. What is your life style for keeping healthy? _____________________________ _____________________________________________________________________ 38. What percent of the time do you adhere to it? __________________________ _____________________________________________________________________ 39. What emotions are you aware of feeling before you get sick? ______________ _____________________________________________________________________ 40. I get sick ____ number of times a year (including colds, allergies, upset stomachs, back pain,

etc.) 41. Re-count carefully _____ 42. I usually get sick when ________________________________________________ _______________________________________________________________________ 43. I look forward to people being sympathetic to me when I get sick: ___ yes ___ no 44. What did others in your family get by being sick (as you were growing up)? ____ ________________________________________________________________________ ________________________________________________________________________ 45. What did they get out of doing by being sick? ______________________________ ________________________________________________________________________ 46. What did you get by being sick? _________________________________________ ________________________________________________________________________ 47. What did you get out of doing by being sick? ______________________________ ________________________________________________________________________ 48. What did other members of your family say about getting colds or the flu? _____ ________________________________________________________________________ 49. What do you think or say when you get the first signs of a cold or flu? _________ ________________________________________________________________________ 50. What do you think or say when someone around you says, “I think I am coming down with a

cold (or the flu)”?_____________________________________________ _______________________________________________________________________ 51. What do you do at the first sign of a cold, allergy, or flu?____________________ _______________________________________________________________________

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52. If you were diagnosed with a serious illness, what would you (or what did you) think or say?

_________________________________________________________________________________ 53. If you get sick, do you tend to blame yourself? ____ yes ____ no 54. If you get sick, do you tend to blame someone else? ____ yes ____ no 55. If you get the flu or cold do you blame it on that latest bug going around? ____ yes ____ no 56. Have you had a significant illness in the past? ___ yes ___ no. If yes, what ____ _______________________________________________________________________ 57. What did it keep you from doing that was important to you? ________________ _______________________________________________________________________ 58. What did it get you out of doing? _______________________________________ 59. What did it get for you? _______________________________________________ 60. Do you have allergic reactions? ___ yes ____ no 61. What do you see as a cause of your allergic reaction? _______________________ _______________________________________________________________________ 62. Do you refer to them as “my allergies”? ____ yes ____ no 63. Do you suffer from back pain? ____ yes ____ no 64. What do you think causes your back pain? _______________________________ _______________________________________________________________________ 65. Can you think of any metaphorical meaning to any illness (small or large) that you have had

(recent or past)? _____________________________________________ ________________________________________________________________________ 66. I often worry about getting sick ___ often ____sometimes ____never 67. What emotions or attitudes are difficult or easy for you to express?

Place an “E” by those that are easy.

Place a “D” by those that are difficult to feel or express. Place an “F” by those that you feel with great frequency.

Place an “N” by those that you never allow yourself to feel or express.

____ Fear ____ Dependency ____ Annoyance ____ Deprivation ____ Anger ____ Hatred ____ Sorrow ____ Grief ____ Forgiveness ____ Affection ____ Sadness ____ Joyfulness ____ Love ____ Jealousy ____ Happy ____ Rage ____ Acceptance ____ Anxiety ____ Resentment ____ Shoulds ____ Hurt ____ Rejection ____Judgment ____ Shame ____ Delight ____ Grateful ____ Appreciation ____ Peace ____ Pain ____ Mad ____ Lonely ____ Guilt ____Empathy ____ Calm ____ Ought ____ Sexual ____ Lust ____Embarrassment ____ Anger ____ Passion

68. I feel guilty when I get sick ___ often ____ sometimes ____ never 69. How often do you feel stressed? ____ all the time ___ frequently ___ never ____ occasionally. How strong is your stress? LOW ___(1) ____(2) ____(3)_____ (4)____ (5)____ HIGH____

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70. What do you see as the source of your stress?

_____________________________________________________________________ 71. What are your thoughts about each stressor? ____________________________ ______________________________________________________________________ 72. I enjoy my work: ___ immensely ___ moderately ____very little ____ not at all. 73. I am happy: ___ always ___ most of the time ____lot of the time ____ occasionally ____ rarely 74. Do you often say, “My back (neck, head, stomach, etc) is killing me? ___ yes ___ no 75. I have suffered significant losses in my life: ___ yes ___ no. If yes, please list who, what and

when: __________________________________________________________ ________________________________________________________________________ 76. I had other significant painful experiences in my life: ____ yes ____ no. If yes, please list

them with age of concurrence: ________________________________ _______________________________________________________________________ 77. I have had significant accidents/injuries: ___ yes ___ no. If yes, what: ________ _______________________________________________________________________ 78. I have had significant surgeries: ____ yes ____ no. If yes, what and when? ___ ______________________________________________________________________ ______________________________________________________________________ 79. I was abused as a child: ____ yes ___ no. If so, when and by whom? ________ ______________________________________________________________________ If yes, emotionally ___ yes ___ no. If so, when and by whom? _________________ ______________________________________________________________________ If yes, physically ___ yes ___ no. If so, when and by whom? __________________ If yes, sexually ____ yes ____ no. If so, when and by whom? __________________ ____________________________________________________________________

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ANSWER EACH OF THE FOLLOWING QUESTION WITH A “YES” OR “NO” FIRST. To get a more accurate answer, use muscle testing or see if your head wants to move in a nod for “yes” or if it feels like shaking a “no.” THEN ON A SCALE OF “0" to 10, HOW STRONGLY DO YOU BELIEVE THE FOLLOWING: For example: “0" means you don’t believe it; “5" means you believe it moderately; “10" you totally believe it. Pick a number between 1 and 10: (To get a more accurate reading than self assessment, use muscle testing or the above method). ANY NEGATIVES SHOULD BE CLEARED WITH THE EFT OR THE EFTA IN ORDER TO ALLOW HEALING. 80. I am worthy of having a healthy life ____. 81. I am not worthy of having a healthy life ____. 82. It’s safe to have a healthy life ____. 83. It’s not safe to have a healthy life ____. 84. It will benefit everyone for me to be healthy ____. 85. It will not benefit anyone for me to be healthy ____. 86. This sickness is inevitable because it runs in my family ____. 87. I can be healthy even if it runs in my family ____. 88. I’m afraid of losing a part of my old identity if I am healthy____. 89. It’s OK to lose this part of my old identity if I am healthy____. 90. I am sick because I am being punished _____. 91. I am free of all guilt ____. 92. If “it is going around” I am sure to catch it ____. 93. I will stay strong and healthy, even it “it” is going around _____. 94. I will do what it takes to be healthy____. 95. I won’t do what it takes to be healthy ____. 96. I choose to be healthy right now ____. 97. I want to wait a little while longer before I am healthy ____. How long _____? 98. I am afraid of embracing my full power? ____. 99. I am quite comfortable in embracing my full power. ____ 100. I am afraid of embracing my full power to heal _____. 101. I am quite comfortable embracing my full power to heal _____. 102. I am afraid of losing my identity as one who is powerless to heal myself _____. 103. It’s OK to lose my old identity as one who is powerless to heal myself _____. 104. I am guilty and need to pay the price _____. 105. I am over my guilt _____. 106. I will lose something if I am well _____. 107. I will not lose anything important if I am well_____.