INTEGRATIVE HEALTH AND WELLNESS ASSESSMENT™

Design & Wellness Center

(Used with permission from B. M. Dossey, S. Luck and B. G. Schaub. 2012 Nurse Coaching for Health and Wellness. Huntington, NY: Florence Press) 

This INTEGRATIVE HEALTH AND WELLNESS ASSESSMENT™ (short form) is intended for informational purposes only. It is not a substitute for professional medical advice, diagnosis or treatment.

DIRECTIONS: This questionnaire contains statements about your present lifestyle, feelings, and personal health 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 noting the score of one of the following:

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

For each section (i.e life balance etc.) total your score and type in the text box. You may add comments in the text box related to strenghts or any areas of improvement where a score of 3 or lower was assigned. You will then total your final score (all sections) at the end of the assessment. Your nurse coach will discuss results with you.

Life balance/Satisfaction _________________________/20___________

 

1. I have balance between my work, family, friends, and self.

 1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

2. I get 6-8 hours of uninterrupted sleep each night.

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

3. I use strategies (breathing, stretching. relaxation, meditation, imagery) to manage stress daily.

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

4. When I recognize negative thoughts, I reframe them.

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

Relationships___________________________/15____________

 

5. I have people in my life who I trust and can go to for support and guidance.

  1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

6. I am able to say no to others without feeling guilty.

  1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

7. I clearly express my needs and desires.

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

Spiritual___________________________/15____________

 

8. I feel that my life has meaning, value, and purpose. 

  1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

9. I feel connected to a force greater than myself. 

  1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

10. I make time for reflective practice (affirmations, prayer, meditation etc.).

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

 

Mental___________________________/15____________

 

11. I set realistic goals.

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

12. I ask for help/assistance as needed.

 1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

13. I can accept circumstances and events that are beyond my control. 

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

Emotional___________________________/20____________

  

14. I recognize my own feelings and emotions.

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

15. I express my feelings in appropriate ways.

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

16. I practice forgiveness.

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

17. I listen to and respect the feelings of others.

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

 

Physical/Nutrition___________________________/20____________

 

18. I eat at least 5 servings of fruits and vegetables daily.

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

19. I eat recommended servings of whole foods (beans, nuts etc).

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

20. I drink 6-8 glasses of water daily. 

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

21. I eat mindfully (concentrate on eating-not multitasking or in front of the tv).

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

 

Physical/Exercise___________________________/20____________

 

22. I do aerobic exercise regularly (20-30 min 3x a week).

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

23. I do strength exercises regularly.

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

24. I do stretching or flexibility for 5 min 3x a week.

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

25. I maintain an ideal weight.

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

Environment___________________________/20____________

 

26. I have a healthy non toxic home environment.

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

27. I have a healthy non toxic work environment. 

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

28. I'm aware of how my external environment affects my health & wellbeing.

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

29. I have a smoke free environment.

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

 

Health Responsibility___________________________/35____________

 

30. I believe I am key to my wellbeing.

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

31. I receive a yearly physical exam.

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

32. I pay attention to my physical wellbeing and address symptoms as they arise.

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

33. I know my blood pressure, triglycerides, cholesterol and glucose levels.

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

34. I can work and do regular activities of daily life.

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

35. I am aware of my risk factors for disease.

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always

 

36. I follow the plan/medications developed with my health care provider.

1=never; 2=rarely; 3=occasionally; 4=frequently 5= always