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Questionnaire

Your Life Balance & Performance Snapshot

This assessment helps us map your focus pattern, habit loops, stress response, and emotional regulation. Based on your answers, we recommend the right starting protocol (21-Day / 3-Month / 1-Year).

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Estimated time: 6–10 minutes
Answer honestly. There are no “good” answers — we’re looking for patterns, not perfection. Your responses are private and used only to guide your plan.
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Section 1: Focus & Attention
How your attention behaves during tasks, distractions, and interruptions.
Q1: I can stay focused on a single task for long periods without getting distracted. *
Q2: I often lose track of what I was doing because my mind wanders. *
Q3: When working, I find it easy to ignore background noises. *
Q4: I usually complete tasks even when they are boring. *
Q5: I tend to start several tasks without finishing them. *
Q6: It is difficult for me to concentrate unless I’m extremely interested in something. *
Q7: I get distracted by my phone or other devices more often than I’d like. *
Q8: I can stay organized and keep track of deadlines easily. *
Q9: I need frequent breaks to maintain my concentration. *
Q10: I find it easy to return to a task after being interrupted. *
Section 2: Impulse, Dopamine & Habits
Phone loops, cravings, impulsivity, and difficulty stopping rewarding behaviors.
Q11: I often act without thinking through the consequences. *
Q12: I tend to use food, screens, or substances to cope with stress. *
Q13: I find it challenging to stop myself once I start doing something pleasurable (e.g., gaming, scrolling, snacking). *
Q14: I frequently regret decisions made on impulse. *
Q15: I rely on caffeine, sugar, or stimulants to stay alert. *
Q16: I sometimes feel compelled to check my phone even when I don’t need to. *
Q17: I struggle to control habits that I know are unhealthy. *
Q18: I often seek quick rewards rather than long-term benefits. *
Q19: I tend to procrastinate and then rush impulsively at the last minute. *
Q20: I find myself repeating behaviors even when they have negative consequences. *
Section 3: Mood, Energy & Motivation
Energy, motivation, interest, and emotional heaviness patterns.
Q21: I often feel sad, down, or emotionally empty. *
Q22: I feel like I have less energy than most people. *
Q23: I have lost interest in activities I once enjoyed. *
Q24: I struggle to motivate myself to do everyday tasks. *
Q25: I experience feelings of worthlessness or excessive guilt. *
Q26: My sleep patterns are irregular or unsatisfying. *
Q27: I have difficulty experiencing positive emotions. *
Q28: I feel disconnected from people around me. *
Q29: I often feel overwhelmed by simple responsibilities. *
Q30: I feel discouraged about the future. *
Section 4: Anxiety & Stress Response
Worry, tension, physical stress symptoms, and reaction to uncertainty.
Q31: I worry about many different things throughout the day. *
Q32: I find it difficult to relax even when nothing is wrong. *
Q33: I often feel tense or “on edge.” *
Q34: My thoughts sometimes race uncontrollably. *
Q35: I avoid situations that make me anxious. *
Q36: I get physical symptoms of stress (e.g., headaches, stomach issues). *
Q37: I spend a lot of time thinking about worst-case scenarios. *
Q38: I feel overwhelmed easily by unexpected changes. *
Q39: I become anxious when I lack structure or routine. *
Q40: I often replay negative events in my mind. *
Section 5: Emotional Regulation & Sensitivity
Emotion control, sensitivity to criticism, overwhelm, and adaptability.
Q41: I have difficulty regulating my emotions. *
Q42: I am highly sensitive to criticism or rejection. *
Q43: Stressful events affect me more strongly than they seem to affect others. *
Q44: I sometimes dissociate or “zone out” when overwhelmed. *
Q45: My thoughts often feel disorganized or scattered. *
Q46: I have a family history of mental-health conditions. *
Q47: I tend to isolate myself when I feel upset. *
Q48: I experience sharp mood changes throughout the day. *
Q49: I find it difficult to adapt to new or unfamiliar situations. *
Q50: I often feel misunderstood or different from others. *
By submitting, you confirm the details are correct. We use your responses only for guidance and support.
Tip: Your answers are saved locally in your browser while you fill this (so accidental refresh won’t erase progress).
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