Integrative Health and Wellness Assessment

Integrative Health and Wellness Assessment™

- IHWA Long Form 2.0 -
You are invited to participate in the Integrative Health & Wellness Assessment™ (IHWA). The IHWA is a self-completed tool that represents the eight dimensions of wholeness. This creates an awareness and deepening of the connection to your inner wisdom.

Complete this to begin you journey into making transformational health and wellness changes. It will take approximately 10-25 minutes to complete the assessment.

Note:
- Data will be collected anonymously and will only be used for research.
- No names or personal identifying information will be used.
- Your responses will be strictly confidential and data from this research will be reported only in the aggregate.
- Your information will be coded and will remain confidential.
- The IHWA is intended for informational purposes only. It is not a substitute for professional medical advice, diagnosis or treatment.
If you have questions at any time about the assessment or the procedures, you may contact Dr. Karen Avino at KAvino@inursecoach.com.

Name

First NameLast Name
Your Initials
Your Email
example@example.com
This INTEGRATIVE HEALTH and WELLNESS ASSESSMENT (long 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 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 Balance / Satisfaction

Life Balance / Satisfaction*

	1	2	3	4	5
1. I feel content with the integration between my work, family, friends, & self.
2. I appreciate who I am.
3. I am satisfied with my work and/or profession.
4. I feel joy and gratitude.
5. I am hopeful about the future.
6. I look forward to going to work each day.
7. I give time and resources to people and causes I admire.
8. I am comfortable with my financial situation.
9. I am coping well with life.
10. I focus on my strengths.
11. I get 6-8 hours of uninterrupted sleep each night.
12. I wake up feeling rested and alert.
13. I use daily strategies to manage my stress (ex: breathing, stretching, relaxation, meditation, imagery).
14. I use daily positive self-talk and affirmations.
15. I set realistic goals.
16. I can release anxiety, worry, and fear in a healthy way.
17. I manage my time to meet my personal goals.
18. I take time for leisure activities (ex: gardening, hobbies, etc.).
19. I take short breaks for play, laughter, and humor each day.
20. I take on no more than I can manage.

Life Balance Total Points
Life Balance Max Points
Life Balance Percentage

Relationships

Relationships*

	1	2	3	4	5
1. I participate in satisfying relationships.
2. I have people in my life that I trust and can go to for support and guidance.
3. I feel comfortable sharing my feelings/opinions without feeling guilty.
4. I am able to set boundaries and say no to others without feeling guilty.
5. I express my feelings to others in appropriate ways.
6. I am happy with the quality and quantity of nurturing physical contact that I have with others (ex: hugs, bodywork, partner yoga).
7. I easily express love and concern to those I care about.
8. I do my part in establishing and maintaining relationships.
9. I feel comfortable with my sexuality.
10. I am happy with the quality and quantity of sexual intimacy in my life right now.
11. I can talk about feelings related to death and other losses with friends and/or family.
12. I have taken actions to ensure that my end-of-life care is as I would want it to be (ex: Health Care Proxy, Living Will, Power of Attorney).

Relationships Total Points
Relationships Max Points
Relationships Percentage

Spiritual

Spiritual*

	1	2	3	4	5
1. I feel that my life has meaning, value, and purpose.
2. I feel connected to a force greater than myself.
3. I feel in touch with my inner wisdom.
4. I have experiences of feeling awe and wonder.
5. I feel joyfulness and gratitude.
6. I follow a spiritual and/or religious practice.
7. I make time for reflective practice (ex: affirmation, prayer, meditation).
8. I feel that I am growing and changing in positive ways.
9. I have a community that will be there for me in times of need (ex: illness, crisis, death).

Spiritual Total Points
Spiritual Max Points
Spiritual Percentage

Mental

Mental

	1	2	3	4	5
1. I am open and receptive to new ideas and experiences.
2. I use my imagination in considering new choices or possibilities.
3. I am interested in and knowledgeable about many topics.
4. I set realistic goals for my work.
5. I enjoy developing new skills and talents.
6. I recognize negative thoughts and reframe them.
7. I am aware of the connection between my thoughts, emotions, and health.
8. I ask for help/assistance as needed.
9. I am committed and disciplined when I take on new projects.
10. I follow through and work on decisions with clarity and actions steps.
11. I take important challenges as needed.
12. I can accept circumstances and events that are beyond my control.

Mental Total Points
Mental Max Points
Mental Percentage

Emotional

Emotional

	1	2	3	4	5
1. I release unwanted feelings (ex: anxiety, worry, fear, and anger) in a healthy way.
2. I laugh freely and openly.
3. I include my feelings when making decisions.
4. I recognize my intuition.
5. I can learn from my mistakes.
6. I am compassionate with myself.
8. I practice forgiveness.
8. I am authentic in my communication(s).
9. I listen to and respect the feelings of others.
10. I enjoy new challenges or experiences.
11. I seek guidance if necessary.

Emotional Total Points
Emotional Max Points
Emotional Percentage

Physical

Physical/Nutrition

	1	2	3	4	5
1. I eat a nutritious breakfast daily.
2. I eat at least 5 servings of vegetables and fruits daily.
3. I eat whole foods (ex: grains, beans, seeds, nuts).
4. I am aware that high fat foods are not healthy (ex: trans fats, fried foods).
5. I drink 6 to 8 glasses of water daily.
6. I read labels for ingredients.
7. I eat healthy food (ex: whole, non-processed, organic).
8. I eat my meals at home.
9. I have access to healthy food choices.
10. I am aware of foods that affect my digestion.
11. I am aware of any food sensitivities or food allergies.
12. I have a daily bowel movement.
13. I chew my food thoroughly.
14. I eat mindfully (ex: I concentrate on my eating, not multi-tasking or eating in front of the television).
15. I refrain from eating late at night.
16. I am aware of portion size and how much food I need.
17. I feel energy after eating.

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

Physical/Exercise

	1	2	3	4	5
1. I include exercise and/or movement as part of my daily routine.
2. I recognize when my body is in need of exercise and movement.
3. I do stretch or flexibility activities 2 or more days a week.
4. I do muscle-strengthening activities (ex: free-weights, machines, resistance bands, body weight exercises, or carrying heavy loads) for all major muscle groups (ex: legs, back, core, chest, arms) 2 or more days a week.
5. I do moderate-intensity aerobic activity (ex:, brisk walking, or any activity that makes you breathe harder with an increased heart rate) for at least 150 minutes (2 hours & 30 minutes) a week.
6. I am aware of the connection between exercise and health.
7. I recognize my resistance to a regular exercise plan.
8. I feel comfortable exercising in public places (ex: gym, park, class).

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

Physical/Weight

	1	2	3	4	5
1. I maintain my ideal weight.

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

Environmental

Environmental

	1	2	3	4	5
1. I have a healthy, non-toxic home environment (ex: chemicals, noise, light).
2. I have a healthy, non-toxic home environment (ex: chemicals, noise, light).
3. I am aware of the influence of my external environment (ex: physical, social, climate, energy patterns) on my health and wellbeing.
4. I share environmental awareness with others in my workplace and community.
5. I make healthy environmental choices when I can.
6. I check my home for mold.
7. I use a water filter in my home.
8. I use natural pesticides whenever possible in my home, garden, or lawn.
9. I take precautions with my hobbies or work that involves chemicals (ex: painting, stained glass, woodwork).
10. I refrain from using a flea collar or other topical chemical treatment on my pets.
11. I live in a smoke-free environment.
12. I am aware that what I apply to my skin absorbs into my body.
13. I read labels and check ingredients for my personal care products.
14. I use environmentally-friendly cleaning products in my home and/or workplace.
15. I dry clean clothes and remove the plastic before hanging them in my closet.
16. I microwave my food in glass and avoid plastics.
17. I use my cell phone and hold it away from my ear or use an earpiece or headset.
18. I purchase new products (ex: shower curtain, carpeting, furniture) and ventilate the area or leave the product outside until the "off-gas" smell disappears.

Environmental Total Points
Environment Max Points
Environmental Percentage

Health Responsibility

Health Responsibility

	1	2	3	4	5
1. I believe I am key to my wellbeing and overall health.
2. My overall health is excellent.
3. I receive yearly physical exams.
4. I am aware of my risk factors for disease.
5. I address unusual physical signs or symptoms as they arise.
6. I have had a baseline eye examination and get regular eye examinations as recommended for my age.
7. I practice good oral hygiene (ex: flossing, toothpicks, dental cleaning).
8. I receive regular dental preventive care (teeth cleaning every 6 months).
9. I check my skin for changes or suspicious moles.
10. I recognize changes in bowel patterns and seek professional consultation if not corrected by lifestyle change.
11. I know my blood pressure, cholesterol, triglycerides, and glucose levels.
12. I avoid smoking, vaping, or inhaling substances into my lungs.
13. I can work and do regular activities of daily life.
14. I get 7 or more hours of quality sleep per night.
15. I buckle my seatbelt when driving or when riding as a passenger.
16. I avoid talking on my cell phone when driving or doing critical tasks.
17. I have been free of pain or injury for the last 6 months.
18. I am free from an addiction to a substance or behavior (ex: nicotine, alcohol, drugs, sex, food, gambling, shopping, exercise, internet).
19. I have completed a personal health record and know where to access it.
20. I am engaged in the development of my wellness plan (ex: health screenings, medication, supplements, fitness, nutrition, etc.)

Health Responsibility Total Points
Health Responsibility Max Points
Health Responsibility Percentage

Goals and Action Plan

Total Change Scores


Life Balance / Satisfaction
Relationships
Spiritual
Mental
Emotional
Physical/Nutrition
Physical/Exercise
Physical/Weight
Environmental
Health Responsibilty

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= 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

Life Balance and Satisfaction Action Plan
Relationships Action Plan
Spiritual Action Plan
Mental Action Plan
Emotional Action Plan
Nutrition Action Plan
Exercise Action Plan
Weight Management Action Plan
Environmental Action Plan
Health Responsibility Action Plan
Review the Total Change Scores and determine what areas of Health & Wellness you wish to address. (Check all that apply)*

Life Balance and SatisfactionRelationshipsSpiritualMentalEmotionalPhysical - NutritionPhysical - ExercisePhysical - Weight ManagementEnvironmentalHealth Responsibility
Identify one long term goal (>1 year) related to an area of wellness that is most important to you to address.
Goal #1
Goal #1 - How will you begin?
Goal #1 - When will you begin?
Goal #1 - How often will you do it?
Goal #2
Goal #2 - How will you begin?
Goal #2 - How often will you do it?
Goal #2 - When will you begin?
Goal #3
Goal #3 - How will you begin?
Goal #3 - When will you begin?
Goal #3 - How often will you do it?

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Integrative Health and Wellness Assessment™