Music4Life Self-Assessment

Part A:
Check any conditions you experience regularly over the last week:

Anger
Anxiety
Confusion, indecisiveness
Depression
Difficulty concentrating
Difficulty relaxing or meditating
Emptiness, boredom
Exhaustion
Fear
Frustration		 Grief, sadness
Headaches
Insomnia
Irritability, on edge
Lack of self-esteem
Loss of appetite
Procrastination
Relationship problems
Stress
Worry

Part B: Identify your experience over the last week of each emotion using the following key:

1 - Almost never 2 - Sometimes 3 - Often 4 - Most always

"U" - Unsettled Emotions :

Anxiety/fear : 1 2 3 4
Anger/hate 1 2 3 4
Depression 1 2 3 4
Grief/Sadness 1 2 3 4

"S" - Soothed Emotions :

Peaceful: 1 2 3 4
Content: 1 2 3 4
Relaxed: 1 2 3 4
Self-Nurturing: 1 2 3 4

"E" - Energized Emotions :

Playful: 1 2 3 4
Happy: 1 2 3 4
Enthusiastic: 1 2 3 4
Optimistic: 1 2 3 4