This is about what one’s actual way of life is.  Rate it as it currently is and then decide where you want to be.  (Print the form or paste it into a word document.)

Scoring:  Score your compliance with these statements as follows (each score shows how true or the amounts of time you believe that statement is true for you):

0 = Not at all true for me
1 = Somewhat true or true only part of the time
2 = Fairly true or true about half the time
3 = mainly true or true most of the time
4 – True all of the time

___ 1. I accept complete responsibility for my own well-being, for everything I
         think, say, do and feel.

___ 2.  I am my own authority for everything I do, and direct my life in
          constructive channels.

___ 3.  I make decisions promptly and willingly accept the consequences.

___ 4.  I discipline myself through monitoring my thoughts, desires, images, and

___ 5.  I think for myself and act accordingly.

___ 6.  I allow myself the freedom to make mistakes, to be “wrong,” to fail,  to be
          free of self-accusation, guilt or feeling “less than.”

___ 7.  I take deep satisfaction in doing my work conscientiously and well.

___ 8.  I approach every problem and new endeavor with confidence.

___ 9.  I do not blame others for my problems, mistakes, defeat or handicaps.

___ 10.  I do not procrastinate or drift; I motivate myself in life with my chosen
            life objectives.

___ 11.  I follow all undertakings through to a logical conclusion.

___ 12. I do not allow personal comparisons to affect my sense of worth.

___ 13.  I do not try to prove my worth by my accomplishments.

___ 14. I defer to no one on account of wealth or status.

___ 15. I do not blame myself for my mistakes, defeats or failures.

___ 16. I stand up for my own values, opinions and convictions.

___ 17. I refrain from no endeavor because of fear of failure or defeat.

___ 18. I do not require others’ confirmation or agreement and approval to do as
           I myself see fit.

___ 19. I do not let others talk me into things against my better judgment.

___ 20.  I am patient, kind and gentle with myself.

___ 21. I take the initiative in personal contacts and relationships.

___ 22.  I walk erect and face everyone with a friendly countenance.

___ 23.  I do not deny my needs, feelings or opinions to please others.

___ 24.  I am frank and open with everyone, free of all masks and pretensions.

___ 25. I do not try to impress others with my worth or importance.

___ My lifestyle index total score on ___/__/___.

___ My long term target score (I recommend at least 80 or better yet 90.)

File in My Psychology Notebook or My About Me Notebook. 

Action Statements - Lifestyle Evaluations No. 70
Copyright 1989 The Barksdale Foundation