Please note that this scale is not a clinical diagnostic instrument and is provided for educational purposes. It merely examines some of the more effective physical, psychological and spiritual methods of staying balanced and preventing burnout. If you have any concerns about your state of emotional health, you should consult with a mental health professional.

Instructions: In the last month, how often has the following been true for you? For each question, write the number that best fits your experience on the line before the question.

1. I have at least one full day off work each week.

(0) Never / (1) Seldom / (2) Sometimes / (3) Often / (4) Always

2. I take some time for myself to be quiet, think, meditate, write and/or pray.

(0) Never / (1) Seldom / (2) Sometimes / (3) Often / (4) Daily

3. I work for less than ten hours a day.

(0) Never / (1) Seldom / (2) Sometimes / (3) Often / (4) Daily

4. I do aerobic exercise (walking, running, swimming etc) for at least 25 minutes at a time.

(0) Never / (1) Seldom / (2) Once a week / (3) Twice a week / (4) 3 or more times/week

5. I do something I find fun (e.g., play a game, go to a movie, read a book etc).

(0) Never / (1) Seldom / (2) Sometimes / (3) Often / (4) Daily

6. I practice muscle relaxation, Pilates, yoga, stretching, meditation or slow breathing techniques.

(0) Never / (1) Seldom / (2) Sometimes / (3) Often / (4) Daily

7. I share how I am feeling with at least one friend or my partner.

(0) Never / (1) Seldom / (2) Sometimes / (3) Often / (4) Daily

8. I sleep well and get at least seven hours of sleep a night.

(0) Never / (1) Seldom / (2) Sometimes / (3) Often / (4) Daily

9. I am careful about what I eat and eat a balanced diet.

(0) Never / (1) Seldom / (2) Sometimes / (3) Often / (4) Daily

10. I drink at least 1.5 liters of water (approx. 3 pints) a day.

(0) Never / (1) Seldom / (2) Sometimes / (3) Often / (4) Always

11. I laugh without malice or cynicism.

(0) Never / (1) Seldom / (2) Sometimes / (3) Often / (4) At least once a day

12. When I leave work at the end of the day I can disengage and leave the pressures of work behind.

(0) Never / (1) Seldom / (2) Sometimes / (3) Often / (4) Always

13. I listen to my body’s signals and recognize when I am becoming tired, rundown and vulnerable to illness.

(0) Never / (1) Seldom / (2) Sometimes / (3) Often / (4) Always

14. There are people who care about me that I trust, to whom I can talk if I want.

(0) Never / (1) Seldom / (2) Sometimes / (3) Often / (4) Always

15. I do something I find creative or expressive (e.g., writing, cooking, gardening etc).

(0) Never / (1) Seldom / (2) Sometimes / (3) Often / (4) Daily

16. I feel I have the training and skills I need to do my job well.

(0) Never / (1) Seldom / (2) Sometimes / (3) Often / (4) Always

17. I set and maintain healthy boundaries for myself by standing up for myself, saying “no” when I need to, and not letting others take advantage of me.

(0) Never / (1) Seldom / (2) Sometimes / (3) Often / (4) Always

18. At work I take a brief break at least every two hours, and switch tasks regularly so that I don’t become too drained.

(0) Never / (1) Seldom / (2) Sometimes / (3) Often / (4) Always

19. I spend time with groups of people I trust and to whom I feel close who are part of a community of meaning and purpose (e.g., a church group, a group of volunteers, work colleagues).

(0) Never / (1) Seldom / (2) Sometimes / (3) About once a week / (4) More than once a week

20. My ability to communicate with others is...

(0) Very poor / (1) Poor / (2) Fair / (3) Good / (4) Excellent

21. I feel good about how I spend my time and energy in relation to what is really important to me in life.

(0) Never / (1) Seldom / (2) Sometimes / (3) Often / (4) Always

22. I believe in myself and generally give myself positive messages about my ability to accomplish my goals – even when I encounter difficulties

(0) Never / (1) Seldom / (2) Sometimes / (3) Often / (4) Always

23. I set realistic goals for my life (both short term and long term) and work towards them consistently.

(0) Never / (1) Seldom / (2) Sometimes / (3) Often / (4) Always

24. I take good vacations (at least one two-week vacation every year).

(0) Never / (1) Seldom / (2) Sometimes / (3) Often / (4) Every year

25. I drink alcohol, smoke, or use other recreational drugs

(0) Three or more times every day / (1) At least once every day / (2) Three to six times a week / (3) Less than three times a week / (4) Never

TOTAL SCORE: ____________

Interpretation Guidelines

0-25: A score in this range suggests that your self care skills and lifestyle balance strategies may be poor, and that you could possibly benefit from developing a plan to change your lifestyle and improve your self-care.

26-50: A score in this range suggests that your self care skills and lifestyle balance strategies may be poor to average, and that you could possibly benefit from developing a plan to improve your self-care.

51-75: A score in this range suggests that you may have moderately good self-care skills and lifestyle balance strategies in place.

76-100: A score in this range suggests that you may have good self-care skills and lifestyle balance strategies in place.

List 2-3 things you can do to improve your self-care.

SOURCE: headington-institute.org