Integrative Health and Wellness Assessment

Integrative Health and Wellness Assessment™

- IHWA Short Form V2.0 -
Instructions for Participation and Data Use

The data you provide during this process may be used for research purposes to help us better understand changes in health and wellness outcomes resulting from Nurse Coaching. Completion of the form signifies your agreement to participate.

Please note the following important points:
- Anonymity: Your responses will not be linked to your name or any personally identifiable information.
- Confidentiality: All information you provide will be stored securely and only accessed by authorized researchers. Results will be reported in a way that does not identify any individual participant.
- Voluntary Participation: You are free to withdraw at any time without penalty.
- Questions/Concerns/Withdrawals: Please contact Dr. Karen Avino at kavino@inursecoach.com.
Creating Your Personal Identifier

To help us match your responses across different timeframes of form completion, we kindly request that you create a personal identifier that does not reveal your identity.

Please use the following for your personal identifier:
- First 2 letters of your mother's first name
- Last 2 digits of your birth year
- First 2 letters of your birth city
- First Letter of your birth month
Example: If your mother’s first name is “Mary” and you were born in January 1985 in Boston, your identifier would be MA85BOJ.

You will be asked to enter this identifier each time you complete a form.
Personal identifier*
Your Email*

Confirmation Emailexample@example.com
Your Nurse Coach's Email*
example@inursecoach.com

DIRECTIONS: This questionnaire contains statements about your present way of life, feelings, and personal habits. Please respond to each item as accurately as possible, and try not to skip any item.

Indicate the frequency with which you engage in each item by selecting one of the following:

1 = Never

2 = Rarely

3 = Occasionally

4 = Frequently

5 = Always

Life Satisfaction*

	1	2	3	4	5
1. I feel content with the integration between my work, family, friends, & self.
2. I use daily strategies to manage my stress (such as: breathing, stretching, relaxation, meditation, and imagery).

Life Balance Total Points
Life Balance Max Points
Life Balance Percentage

Relationships

	1	2	3	4	5
3. I participate in satisfying relationships.
4. I feel comfortable sharing my feelings/opinion without feeling guilty.
5. I express my feeling to others in appropriate ways.
6. I easily express love and concern to those I care about.

Relationships Total Points
Relationships Max Points
Relationships Percentage

Spiritual

	1	2	3	4	5
7. I feel that my life has meaning, value, and purpose.
8. I feel connected to a force greater than myself.
9. I make time for reflective practice affirmation, prayer, meditation

Spiritual Total Points
Spiritual Max Points
Spiritual Percentage

Mental

	1	2	3	4	5
10. I recognize negative thoughts and reframe them.
11. I set realistic goals for my work.
12. I ask for help/assistance when needed.
13. I can accept circumstances and events that are beyond my control.

Mental Total Points
Mental Max Points
Mental Percentage

Emotional

	1	2	3	4	5
14. I practice forgiveness.
15. I listen to and respect the feelings of others.
16. I release unwanted feelings (anxiety, worry, fear and anger) in a healthy way.

Emotional Total Points
Emotional Max Points
Emotional Percentage

Physical/Exercise

	1	2	3	4	5
17. I do stretch or flexibility activities 2 or more days a week
18. I do muscle-strengthening activities (i.e., free-weights, machines, resistance bands, body weight exercises, or carrying heavy loads) for all major muscle groups (legs, back, core, chest, arms) 2 or more days a week.
19. I do moderate-intensity aerobic activity (i.e., brisk walking, or any activity that makes you breathe harder with an increased heart rate) for at least 150 minutes (2 hours and 30 minutes) a week.

Physical/Excercise Total Points
Physical/Exercise Max Points
Physical/Exercise Percentage

Physical/Nutrition

	1	2	3	4	5
20. I eat at least 5 servings of fruits and vegetables daily
21. I drink 6-8 glasses of water daily.
22. I eat healthy food (ex: whole, non-processed, organic)
23. I eat mindfully (concentrate on eating and not multi-tasking or eating in front of the TV)

Physical/Nutrition Total Points
Physical/Nutrition Max Points
Physical/Nutrition Percentage

Physical/Weight

	1	2	3	4	5
24. I maintain what I consider an ideal weight.

Physical/Weight Total Points
Physical/Weight Max Points
Physical/Weight Percentage

Environmental

	1	2	3	4	5
25. I have a healthy non-toxic home environment (such as: chemicals, noise, light).
26. I have a healthy non-toxic work environment (such as: chemicals, noise, light).
27. I am aware of the influence of the environment (physical, social, climate, energy patterns) on my health.

Environmental Total Points
Environment Max Points
Environmental Percentage

Health Responsibility

	1	2	3	4	5
28. I am free from an addiction to a substance or behavior (alcohol, nicotine, drugs, sex, food, gambling, shopping, exercise, internet).
29. I can work and do regular activities of daily living.
30. I avoid smoking, vaping, or inhaling substances into my lungs.
31. I address unusual physical signs or symptoms as they arise.
32. I get 7 or more hours of quality sleep per night.
33. I know my blood pressure, triglycerides, cholesterol, and glucose levels.
34. I am aware of my risk factors for disease.
35. I am engaged in the development of my wellness plan (such as: health screenings, medication, supplements, fitness, nutrition, etc.)
36. I know I am key to my wellbeing and overall health.

Health Responsibility Total Points
Health Responsibility Max Points
Health Responsibility Percentage

Areas To Address

	My Readiness To Change 1= In one year 2= Within 6 months 3= Next month 4= In two weeks 5=Now	Priority For Making Change (1-5) 1= Never a priority 2= Very low priority 3= Medium priority 4= Priority 5= Highest Priority	Confidence In My Ability To Do It (1-5) 1= Not at all confident 2= Not very confident 3= Somewhat confident 4= Confident 5= Very confident
Life Balance / Satisfaction
Relationships
Spiritual
Mental
Emotional
Physical/Nutrition
Physical/Exercise
Physical/Weight
Environmental
Health Responsibilty

Should be Empty:

Integrative Health and Wellness Assessment™

Instructions for Participation and Data Use

Creating Your Personal Identifier