Holistic Health Assessment

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Answer the questions in each section below and total your score. Each response will be a number from 0 to 5. Please refer to the frequency described within the parentheses (e.g. 2 – 3 times/week) when answering questions about an activity; e.g. “Do you maintain a healthy diet?” However, when the question refers to an attitude or an emotion (most of the Mind and Spirit questions), e.g., “Do you have a sense of humor?” the response is more subjective, less exact, and you can refer only to the items describing the frequency, such as often or daily, but not to the numbered frequencies in parentheses.

0 = Never or almost never (once a year or less)

1 = Seldom (2 to 12 times/year)

2 = Occasionally (2 – 4 times/month)

3 = Often (2 – 3 times/week)

4 = Regularly (4 – 6 times/week)

5 = Daily (every day)

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BODY: Physical and Environmental Health

____ 1. Do you maintain a healthy diet (low fat, low sugar, fresh fruits, grains and vegetables)?

____ 2. Is your water intake adequate (at least ½ oz./lb. of body weight; 160 lbs. = 80 oz.) ?

____ 3. Are you within 20 percent of your ideal body weight?

____ 4. Do you feel physically attractive?

____ 5. Do you fall asleep easily and sleep soundly?

____ 6. Do you awaken in the morning feeling well-rested?

____ 7. Do you have more than enough energy to meet your daily responsibilities?

____ 8. Are your five senses acute?

____ 9. Do you take time to experience sensual pleasure?

____ 10. Do you schedule regular massage or deep-tissue body work?

____ 11. Does your sexual relationship feel gratifying?

____ 12. Do you engage in regular physical workouts lasting at least 20 minutes?

____ 13. Do you have good endurance or aerobic capacity?

____ 14. Do you breathe abdominally for at least a few minutes?

____ 15. Do you maintain physically challenging goals?

____ 16. Are you physically strong?

____ 17. Do you do some stretching exercises?

____ 18. Are you free of chronic aches, pains, ailments and diseases?

____ 19. Do you have regular effortless bowel movements?

____ 20. Do you understand the causes of your chronic physical problems?

____ 21. Are you free of any drug or alcohol dependency (including nicotine and caffeine)?

____ 22. Do you live in a healthy environment with respect to clean air, water and indoor pollution?

____ 23. Do you feel energized or empowered by nature?

____ 24. Do you feel a strong connection with and appreciation for your body, your home and your environment?

____ 25. Do you have an awareness of life-energy or “qi” (from Asian medicine)?

TOTAL BODY SCORE _________

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MIND: Mental and Emotional Health

____ 1. Do you have specific goals in your personal and professional life?

____ 2. Do you have the ability to concentrate for extended periods of time?

____ 3. Do you use visualization or mental imagery to help you attain your goals or enhance your performance?

____ 4. Do you believe it is possible to change?

____ 5. Can you meet your financial needs and desires?

____ 6. Is your outlook basically optimistic?

____ 7. Do you give yourself more supportive messages than critical messages?

____ 8. Does your job utilize all of your greatest talents?

____ 9. Is your job enjoyable and fulfilling?

____ 10. Are you willing to take risks or make mistakes in order to succeed?

____ 11. Are you able to adjust beliefs and attitudes as a result of learning from painful experiences?

____ 12. Do you have a sense of humor?

____ 13. Do you maintain peace of mind and tranquility?

____ 14. Are you free from a strong need for control or the need to be right?

____ 15. Are you able to fully experience (feel) your painful feelings such as fear, anger, sadness, and hopelessness?

____ 16. Are you aware of and able to safely express fear?

____ 17. Are you aware of and able to safely express anger?

____ 18. Are you aware of and able to safely express sadness or cry?

____ 19. Are you accepting of all your feelings?

____ 20. Do you engage in meditation, contemplation, or psychotherapy to better understand your feelings?

____ 21. Is your sleep free from disturbing dreams?

____ 22. Do you explore the symbolism and emotional content of your dreams?

____ 23. Do you take the time to let down and relax, or make time for activities that constitute the abandon or absorption of play?

____ 24. Do you experience feelings of exhilaration?

____ 25. Do you enjoy high self-esteem?

TOTAL MIND/EMOTIONS SCORE _________

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SPIRIT: Spiritual and Social Health

____ 1. Do you actively commit time to your spiritual life?

____ 2. Do you take time for prayer, meditation, or reflection?

____ 3. Do you listen to your intuition?

____ 4. Are creative activities a part of your work or leisure time?

____ 5. Do you take risks or exceed previous limits?

____ 6. Do you have faith in a God, spirit guides, or angels?

____ 7. Are you free from anger toward God or your higher power?

____ 8. Are you grateful for the blessings in your life?

____ 9. Do you take walks, garden, or have contact with nature?

____ 10. Are you able to let go of your attachment to specific outcomes and embrace uncertainty?

____ 11. Do you observe a day of rest completely away from work, dedicated to nurturing yourself and your family?

____ 12. Can you let go of self-interest in deciding the best course of action for a given situation?

____ 13. Do you feel a sense of purpose?

____ 14. Do you make time to connect with young children, either your own or someone else’s?

____ 15. Are playfulness and humor important to you in your daily life?

____ 16. Do you have the ability to forgive yourself and others?

____ 17. Have you demonstrated the willingness to commit to a marriage or compatible long-term relationship?

____ 18. Do you experience intimacy, besides sex, in your committed relationships?

____ 19. Do you confide in or speak openly with one or more close friends?

____ 20. Do you or did you feel close to your parents?

____ 21. If you have experienced the loss of a loved one, have you fully grieved that loss?

____ 22. Has your experience of pain enabled you to grow spiritually?

____ 23. Do you go out of your way or give time to help others?

____ 24. Do you feel a sense of belonging to a group or community?

____ 25. Do you experience unconditional love?

TOTAL SPIRIT SCORE _________

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TOTAL BODY, MIND, SPIRIT SCORE _________

HEALTH SCALE

325 – 375 Optimal Health

275 – 324 Excellent Health

225 – 274 Good Health

175 – 224 Fair Health

125 – 174 Below Average Health

75 – 124 Poor Health

0 – 74 Extremely Poor Health = Surviving\

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Assessment created by The Holistic Health Board