Personal Experience Questionnaire

Good day, participant!

When you agree to participate in this study, you should know that your participation is voluntary and
your identity will be protected. You have the right to refuse to answer any of the questions and you may stop
your participation at any time. You are not required to participate in this study and there is no penalty if you
don’t. There is no identifying information on this questionnaire so any responses are confidential. By filling
out the questionnaire, you are consenting to partake in this study. Thank you for considering the invitation to
participate.
Name __________________________________ Year and Section __________ Gender ___
(Optional)
The following questions relates to your self-care behaviors. There are no right or wrong answers.
Please be honest and underline the answer that reflects your self-care behavior within past
week (7days):

1. Do you feel you get enough sleep?

Yes No
2. Can you name three things in a couple of seconds that will fill your soul with joy?
Yes No
3. Are you able to put yourself first with?
Family Yes No
Friends Yes No
Work Yes No
4. Is taking a vacation a mandate in your life and not an option?
Yes No
5. Is self-care something you practice every date?
Yes No
6. Are you able to easily process your feelings?
Yes No
7. Is exercise a part of your everyday routine?
Yes No
8. Is there time in your week to pursue pleasurable activity (reading, relaxing, friends)?
Yes No
9. Do you feel appreciated in your work at school?
Yes No
10. If you could, would you change your life?
Yes No
Please count the number of “yes” answers that you have answered in the questionnaire and put
that number here ____.

Thank you for giving us your time and effort to participate in this study

Bishop, J. (2018). *** Two-Minute Self-Care Survey. [online] Selfgrowth.com. Available at:
https://www.selfgrowth.com/articles/twominute_selfcare_survey. html.
Personal Experience Questionnaire
Personal Experience Questionnaire
Personal Experience Questionnaire
Personal Experience Questionnaire