7 Domains of Life MasteryP e r f o r m a n c e A n a l y s i s

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MEDICAL DISCLAIMER

The recommendations and information presented during the ỌKAN Performance Analysis are in no way intended as medical advice (diagnosis and/or the treatment of disease), or as a substitute for medical counseling. The information should be used in conjunction with the guidance and care of your physician. If you choose not to obtain the consent of your physician and/or work with your physician throughout the duration of your time using the recommendations from the analysis, you are agreeing to accept full responsibility for your actions and the consequences that may result thereafter.

By continuing with the analysis, you recognize that despite all precautions on the part of ỌKAN International, LLC, there are risks of injury or illness, which can occur because of your use or misuse of the information that is provided here. You expressly assume such risks and waive, relinquish, and release any claim, which you may have against ỌKAN International, LLC, and its representatives, or affiliates as a result of any further physical injury or illness incurred in connection with or as a result of the use or misuse of the analysis provided.

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Height: cm/in

Man Woman Weight: kilo/lb

Name:

Telephone:

Date of Birth:

Sex:

Work:

List three main issues you desire to improve in your life (be specific)?

How long have you been experiencing these issues?

What have you already tried in order to improve these issues?

What motivates you to take action now?

Thank you for filling in the 7 Domains of Life Mastery - Performance Analysis assessment form. Your wellbeing involves being aware of who you are as a whole person. Who you are as a whole person is multi-dimensional and comprises 7 domains. These 7 domains are Spirit, Mind, Emotion, Body, Relationship, Contribution, and Environment. This assessment will explore these 7 domains that constitute health for you as a whole person. Additionally, this assessment will ask some more detailed questions concerning your physical wellbeing, your nutrition habits, hydration, stress levels, alcohol consumption, smoking, and fitness goals. All information collected is crucial in helping us determine the key areas of focus, so you may reach Self-Optimality, the fullest realization of your potential as a whole person, as well as your personal, and professional goals. The information you share is treated as private and confidential, in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and current privacy legislation in Belgium. It is truly an honor to join you on this journey in achieving your desired goals.

GENERAL INTAKE

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DOMAIN OF SPIRIT

1 2 3 4 5Spirit: Strongly Disagree | Disagree | Somewhat Agree | Agree | Strongly Agree

1. I am clear about my spiritual beliefs.2. My spiritual and/or religious practice (prayer, meditation, and/or quiet personal

reflection) are an important part of my life.3. I live very consciously, so that my thoughts, words, and actions are aligned with my

spiritual beliefs.4. I have a very fulfilling spiritual life.5. I have a strong sense of self (who I am and what I am all about).6. I am crystal clear about my purpose in life.7. I am clear about my core values and I can speak about them easily.8. I am grateful for the good things in my life.9. I am always looking for new ways to live a more profound spiritual life.

My Score

Spirit Cultivation- things I'd like to improve spiritually and/or experience:

The Domain of Spirit embodies the life force and conscious awareness that is you. It's the life spark from which your identity, beliefs, and values are created. It is what guides you to leading a meaningful and moral life. It inspires you to live mindfully, while contributing your gifts to the world. It brings purpose and life to the other domains.

Strengths These are three things I do well – my daily routines, habits, and valued life activities that build and maintain my Spirit: 1.

2.

3.

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DOMAIN OF MIND

1. I have a strong sense of who I am and what I am all about.

2. I make time regularly for intellectual stimulation (study, travel, observation, etc.).

3. I am satisfied with my intellectual life.

4. I feel confident in my intellectual abilities.

5. I see learning as a lifelong process.

6. I consistently look to personal development products to enhance my life.

7. I am able to appropriately cope with stress and anxiety.

8. I believe that with my thoughts I am directly creating my reality.

9. I have a strategy in place concerning my intellectual life and know exactly what I needto do to keep learning and growing.

My Score

Mind Cultivation- things I'd like to improve mentally and/or experience:

The Domain of Mind is the aspect of you that thinks, reasons, imagines, creates, and perceives anything and any reality. It has the ability to learn, understand & know through the above processes. It directs expression and provides meaning to the other domains.

Strengths These are three things I do well – my daily routines, habits, and valued life activities that build and maintain my Mind: 1.

2.

3.

1 2 3 4 5Mind : Strongly Disagree | Disagree | Somewhat Agree | Agree | Strongly Agree

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DOMAIN OF EMOTION

1. I am able to recognize and express my feelings.

2. I believe that I have the power to control how I feel.

3. I believe that my emotions have an impact on my body.

4. I seldom experience stress or anxiety.

5. Overall, I am a joyful and happy person.

6. I have a positive attitude towards life.

7. I feel in control of my life

8. I feel that I am truly living my life to the fullest.

9. I have clearly defined my goals concerning my emotional wellbeing (how I want to feeleach day).

My Score

The Domain of Emotion is the source and the cause of your feelings. Your ability to express feelings, experience love, enjoy life with enthusiasm, adjust to emotional challenges, and cope with stress and traumatic life experiences rest in this domain. It brings the sensation of life to the other domains.

Strengths These are three things I do well – my daily routines, habits, and valued life activities that build and maintain my Emotions: 1.

2.

3.

1 2 3 4 5Emotion: Strongly Disagree | Disagree | Somewhat Agree | Agree | Strongly Agree

Emotion Cultivation- things I'd like to improve emotionally and/or experience:

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DOMAIN OF BODY

1 2 3 4 5Body: Strongly Disagree | Disagree | Somewhat Agree | Agree | Strongly Agree

1. I invest time regularly in learning about health and nutrition.

2. I am very happy with the way my body looks.

3. I look and feel younger than my chronological age.

4. My current weight is: My ideal weight is:

5. I have a personalized exercise program that I am fully committed to.

6. I make sure to include a lot of fresh fruits and vegetables in my diet daily.

7. I maintain a high energy level throughout the day.

8. I take proactive steps to avoid and prevent injury, illness and disease by seeking outthe help of a physician, dentist, chiropractor, massage therapist, personal trainer, etc…

9. I have clearly defined my goals concerning the health and fitness levels of my body.

My Score

Body Cultivation- things I'd like to improve physically and/or experience:

The Domain of Body is the domain in which you literally live, breathe, and have your being. It provides you with the means to express yourself here on earth. It's maintained through healthy habits, good nutrition, exercise, and obtaining appropriate health care. It is the vehicle through which the other domains are filtered, experienced and perfected.

Strengths These are three things I do well – my daily routines, habits, and valued life activities that build and maintain my Body: 1.

2.

3.

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DOMAIN OF RELATIONSHIP

My Score

Relationship Cultivation- things I'd like to improve in relating and/or experience:

The Domain of Relationship provides an external mirror to Self. The level and quality of your relationship with yourself, is reflected in the relationships you have with friends, family, and the community at large. It reveals the role that you play in your social engagements and the world as a whole. It brings connection to the other domains.

Strengths These are three things I do well – my daily routines, habits, and valued life activities that build and maintain my Relationships: 1.

2.

3.

1 2 3 4 5Relationship: Strongly Disagree | Disagree | Somewhat Agree | Agree | Strongly Agree

1. I take time for myself daily.

2. I accept myself, both the good and the bad.

3. I allow myself to be vulnerable and make mistakes.

4. I balance my own needs with the needs of others. I can easily say ‘no’.

5. I pay close attention to the relationships that nourish me, versus the relationshipsthat drain me.

6. I have a supportive and loving network of friends and/or family.

7. I have a fantastic and fulfilling romantic relationship.

8. When it comes to being a parent, I feel I am an excellent one.

9. I have clearly defined my goals concerning the kind of relationships I want to buildwith myself and others.

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DOMAIN OF CONTRIBUTION

My Score

Contribution Cultivation- things I'd like to improve in contributing and/or experience:

The Domain of Contribution embodies your contribution to Life. It brings into physical form your unique gifts from the Domain of Spirit. It is you being self-actualized. It involves participating in activities that provide meaning and purpose. The Domain of Contribution consist of your career, work, the value you add to others, and the financial equivalent you receive for the value you have given.

Strengths These are three things I do well – my daily routines, habits, and valued life activities that build and maintain my Contributions: 1.

2.

3.

1. I love what I do in my career and I am very good at it.

2. I manage and control my time very well when it comes to my work and personal life.

3. My work gives me personal satisfaction and challenges me to keep learning andgrowing.

4. I seldom experience career stress.

5. I am easily taking care of all my financial responsibilities.

6. I am very good at managing money.

7. I have set clear financial goals.

8. I am contributing my time and/or money to social and community projects or causesthat benefit individuals and/or society.

9. I am clear on how I desire to contribute and I know exactly how I want to grow in thisarea of my life.

1 2 3 4 5Contribution: Strongly Disagree | Disagree | Somewhat Agree | Agree | Strongly Agree

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DOMAIN OF ENVIRONMENT

My Score

Environment Cultivation- things I'd like to improve environmentally and/or experience:

The Domain of Environment embodies the internal and external reality that is you. It includes your subjective-environment (Domains of Spirit, Mind, Emotion, Body,the places where you live, learn, etc.) and your objective-environment (Domains of Relationship, Work, Environment, your community, country, and the whole planet). It reflects the level of mastery attained and reveals limitations in the other domains.

Strengths These are three things I do well – my daily routines, habits, and valued life activities that build and maintain my Environment: 1.

2.

3.

1 2 3 4 5Environment: Strongly Disagree | Disagree | Somewhat Agree | Agree | Strongly Agree

1. My home provides a space for me where I can be myself and enjoy my life.

2. I am happy with the quality of what I have (house, car(s), furnishings, art or anyother “things” in my life).

3. I keep my living and work environment clean and decluttered.

4. I set aside time to enjoy nature.

5. I regularly schedule time to enjoy and experience the extraordinary things that thisworld has to offer (trips, events, and other highly memorable moments).

6. I live in harmony with the people in my environment.

7. I am very sensitive to my environment.

8. I am committed to a sustainable way of living.

9. I am dedicated to creating the highest quality of life within my environment and Iam clear on which strategies to use.

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GENERAL HEALTH 1. My energy levels on a daily basis are:

1 2 3 4 5 (1 = exhausted / 5 = very energetic)

a) What time do you normally go to sleep?

b) How long does it take you to fall asleep?

c) How many hours do you sleep on average without waking up?

d) At what time do you usually wake up? (with alarm or without?)

e) What score do you give to your night's rest?

1 2 3 4 5

(1 = poor/not feeling rested at all / 5 = excellent/feeling fully rested)

f) Do you need caffeine to start your day?

g) Are you sleepy, tired during your day? If so, what do you do about it?

h) Do you do engage in any sports, exercise etc? If yes, how often do you do it perweek? (strength training, walking, cycling, yoga, swimming, ...)

i) Do you suffer from heart problems, kidney problems, digestive problems, constipation, diarrhea,bloating, pain, gas, acid reflux, diabetes, high blood pressure, stress, anxiety, depression, other mentaland emotional disorders, or any other health problems? Please provide a summary of your current healthissues.

j) When did these problems start?

k) Do you take certain medications? If yes which ones?

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NUTRITION

2. How many portions (a portion is a piece or a handful) of fresh vegetables do you eat on average per day?

3. How many portions (a portion is a piece or a handful) of fresh fruit do you eat on average per day?

4. How many days a week do you usually eat junk food such as chips, fries, cookies, chocolate, candy etc.

5. Do you prefer sweet or salty foods?

6. What is/are your biggest temptation(s)?

7. How often do you cook yourself during the week?

8. How many times a week do you choose frozen meals, order fast food/take out, or go to a restaurants?

9. When you choose pre-made, take out/fast food, or restaurant food, what is the reason (choose the best answer)?

Taste better

I have long working days and therefore no time

I do not know how to make healthy meals

It's more convenient or easier to prepare

It's a habit, because I do not want to cook for myself

Others

10. Do you have allergies/food intolerances that you are aware of? Foods that make you sick? If yes, what areyou allergic to? What are the symptoms?

11. How many meals do you usually eat per day?

12. How often do you go to the toilet a day for a bowel movement?

13. Briefly describe a typical breakfast, lunch, and dinner for you..

14. Do you take nutritional supplements? If yes which ones?

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HYDRATION 15. How many glasses of water do you drink on an average working day?16. What do you drink daily (besides water) and how much do you drink on average?

For example, energy drinks, soft drinks, fruit juice, milk, coffee, (herbal) tea, etc..

ALCOHOL 17. Do you drink alcohol?

Yes No (go to question 18)

a) Do you drink beer, wine, spirits, etc.?

b) How many days a week do you drink?

1-4 days

5-7 days

c)) How many glasses do you drink when you drink?

1 - 2

3 or more

SMOKING 18. Do you smoke? (If not, go directly to question 19)

a) How much do you want to quit smoking (indicate)

(1 = absolutely not / 5 = very much desire)

1 2 3 4 5

b) When you get up in the morning, when do you smoke your first cigarette?More than 60 minutes later

31-60 minutes later

5-30 minutes later

In less than 5 minutes

c) How many cigarettes do you smoke on average per day?

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STRESS ASSESSMENT 19. What score would you give to your daily stress level?

20. In your opinion, how well can you deal with the stress in your life?1 2 3 4 5 (1 = very well / 5 = not at all)

21. Your body is very tense:1 2 3 4 5(1 = Almost always / 5 = Never)

22. You find it difficult to relax, even when you are at home.1 2 3 4 5(1 = Almost always / 5 = Never)

23. You are tired and not really interested in what is happening around you.1 2 3 4 5(1 = Almost always / 5 = Never)

24. What gives you the most stress at this time?

25. What are you doing at the moment to better manage the stress in your life?

26. What is your experience with yoga, meditation, and breathing techniques?

1 2 3 4 5 (1 = much experience / 5 = no experience)

1 2 3 4 5 (1 = Almost always / 5 = Never)

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PHYSICAL FITNESS GOALS 27. Rank your goals in undertaking exercise: What do you want exercise to do for you? Use thefollowing scale to rate each goal separately.

Not Important Somewhat Important ExtremelyImportant

a. Improve cardiovascular fitness

b. Lose weight/body fat

c. Reshape or tone my body

d. Improve performance for a specific sport

e. Improve moods and ability to cope with stress

f. Improve flexibility

g. Increase strength

h. Increase energy levels

i. Feel better

j. Increase enjoyment

k. Social interaction

l. Other

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MISCELLANEOUS

When you look back on your life, when did you feel the best, how did you feel exactly and why did you feel so fantastic?

If you should mention some qualities of yourself, things that you are proud of being very good at, what are they?

What are you grateful for in your life?

What do you miss most at the moment?

If you could make a wish that would come true immediately, what would you change in your life?

What do you think is the cause of the challenges, stress, and/or burnout you are currently facing?

What do you think your body / mind / soul needs to improve at this moment?

What beliefs or fears are currently preventing you from becoming the best version of yourself?

THANK YOU!