Self-Care Assessment Form printable pdf download

Self-Care Assessment

Adapted from Saakvitne, Pearlman, & Staff of TSI/CAAP (1996). Transforming the pain: A

workbook on vicarious traumatization. Norton.

The following worksheet for assessing self-care is not exhaustive, merely suggestive. Feel

free to add areas of self-care that are relevant for you and rate yourself on how often and

how well you are taking care of yourself these days.

When you are finished, look for patterns in your responses. Are you more active in some

areas of self-care but ignore others? Are there items on the list that make you think, "I

would never do that"? Listen to your inner responses, your internal dialogue about self-care

and making yourself a priority. Take particular note of anything you would like to include

more in your life.

Rate the following areas according to how well you think you are doing:

3 = I do this well (e.g., frequently)

2 = I do this OK (e.g., occasionally)

1 = I barely or rarely do this

0 = I never do this

? = This never occurred to me

Physical Self-Care

____ Eat regularly (e.g. breakfast, lunch, and dinner)

____ Eat healthily

____ Exercise

____ Get regular medical care for prevention

____ Get medical care when needed

____ Take time off when sick

____ Get massages

____ Dance, swim, walk, run, play sports, sing, or do some other fun physical activity

____ Take time to be sexual - with myself, with a partner

____ Get enough sleep

____ Wear clothes I like

____ Take vacations

____ Other:

Psychological Self-Care

____ Take day trips or mini-vacations

____ Make time away from telephones, email, and the Internet

____ Make time for self-reflection

____ Notice my inner experience - listen to my thoughts, beliefs, attitudes, feelings

____ Have my own personal psychotherapy

____ Write in a journal

____ Read literature that is unrelated to work

____ Do something at which I am not expert or in charge

____ Attend to minimizing stress in my life

____ Engage my intelligence in a new area, e.g., go to an art show, sports event, theatre

____ Be curious

Self-Care Assessment Form