Integrative Health Assessment
Please complete this assessment to help us understand your overall health and well-being across physical, mental, and lifestyle factors.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Non-binary
Prefer not to say
Other
Please rate the following aspects of your current physical health.
*
Rows
Excellent
Good
Fair
Poor
Energy level
1
2
3
4
Sleep quality
5
6
7
8
Pain or discomfort
9
10
11
12
Appetite
13
14
15
16
Physical activity level
17
18
19
20
How would you rate your mental and emotional well-being?
*
Very Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Very Poor, 10 is Excellent
Which of the following lifestyle factors do you wish to improve? (Select all that apply)
Nutrition/Eating Habits
Physical Activity
Sleep
Stress Management
Work-Life Balance
Social Connections
Other
Please list any current health conditions, diagnoses, or medications.
Please indicate your level of agreement with the following statements.
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I feel supported in my health goals.
21
22
23
24
25
I manage stress effectively.
26
27
28
29
30
I have a positive outlook on life.
31
32
33
34
35
I feel connected to my community.
36
37
38
39
40
Is there anything else you would like to share about your health or well-being?
Submit Assessment
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