A practice of Integrative and Holistic Medicine
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Dr. Peeyush Bhargava is now a Diplomat of the American Board of Integrative Holistic Medicine

Health and Wellness Questionnaire

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 to 3 x /wk) 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.

Your Name*

Your Email*

BODY: Physical and Environmental Health
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)

1. Do you maintain a healthy diet ?
(low fat, low sugar, fresh fruits, grains and vegetables)
2. Is your water intake adequate ?
(at least 1/2 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 an appreciation for your body, your
home and your environment?
25. Do you have an awareness of life-energy or qi?


TOTAL BODY SCORE


MIND: Mental and Emotional Heath
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)

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 your-self 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

SPIRIT: Spiritual and Social Health
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)

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?
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 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

Add up all your scores to find your 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