Priming Self Study
Name_______________________________
Date_____
Instructions: Practice Priming imagery on alternate days this week. On Priming days do the practice at the start of your
day, envisioning a successful day (based on key goals). On non-Priming days, start the day with a To Do List, things you
want to do that day (but do not visualize them). At the end of each day answer the five questions (and items #6-7 at end
of week). Add additional comments about the day in the space provided. Your honest responses are important. Thanks.
Day
Day 1
PRIME
DAY
Day 2
TO DO
LIST
Day 3
PRIME
DAY
Assessment
Very Low
1. Sense of ease for the day?
0
2. Sense of accomplishment for the day?
0
3. Ability to deal with stress, challenges?
0
4. To what extent did you feel enthusiastic? 0
5. To what extend did you feel distressed?
0
Comments
1. Sense of ease for the day?
0
2. Sense of accomplishment for the day?
0
3. Ability to deal with stress, challenges?
0
4. To what extent did you feel enthusiastic? 0
5. To what extend did you feel distressed?
0
Comments
1. Sense of ease for the day?
0
2. Sense of accomplishment for the day?
0
3. Ability to deal with stress, challenges?
0
4. To what extent did you feel enthusiastic? 0
5. To what extend did you feel distressed?
0
Comments
Low Medium High Very High
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
4
4
4
4
4
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
4
4
4
4
4
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
4
4
4
4
4
Day 4
TO DO
LIST
1. Sense of ease for the day?
2. Sense of accomplishment for the day?
3. Ability to deal with stress, challenges?
4. To what extent did you feel enthusiastic?
5. To what extend did you feel distressed?
Comments
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
4
4
4
4
4
Day 5
PRIME
DAY
1. Sense of ease for the day?
2. Sense of accomplishment for the day?
3. Ability to deal with stress, challenges?
4. To what extent did you feel enthusiastic?
5. To what extend did you feel distressed?
Comments
1. Sense of ease for the day?
2. Sense of accomplishment for the day?
3. Ability to deal with stress, challenges?
4. To what extent did you feel enthusiastic?
5. To what extend did you feel distressed?
Comments
Overall Comments
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
4
4
4
4
4
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
4
4
4
4
4
Day 6
TO DO
LIST
Very Low Low Medium High Very High
6. How likely is it that you will continue to use Imagery? 0
1
2
3
4
7. How likely is it that you will continue to use To Do lists?
0
1
2
3
4