Wellness Inventory A survey for members to complete prior to their Program Consultation with a Care Navigator. HiddenNext Steps: Install the Survey Add-OnThis form requires the Gravity Forms Survey Add-On. Important: Delete this tip before you publish the form.Member Information1. Name(Required) First Last 2. Preferred Email Address(Required) 3. Phone Number(Required)4. Date of Birth(Required) MM slash DD slash YYYY 5. Age(Required) 18 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 or over 6. Race/Ethnicity American Indian or Alaska Native Asian Black or African America Native Hawaiian or Other Pacific Islander White Other 7. Gender Male Female Non-binary Transgender Other 8. Home Zip Code(Required) 9. Work Zip Code(Required) Life Balance/SatisfactionPlease rate the following statements from 1 - 5, 1=Never, 2=Rarely, 3=Occasionally. 4=Frequently, 5=Always10. I feel content with the balance between my work, family, friends, and self.(Required) 1 - Never 2 3 4 5 - Always 11. I use strategies daily to manage my stress (e.g breathing, stretching, relaxation, meditation, imagery).(Required) 1 - Never 2 3 4 5 - Always 12. I spend my free time thoughtfully.(Required) 1 - Never 2 3 4 5 - Always 13. I am confident in my ability to make healthy changes in my life.(Required) 1 - Never 2 3 4 5 - Always 14. I value my overall health and wellbeing.(Required) 1 - Never 2 3 4 5 - Always Physical Health/ActivityPlease rate the following statements from 1 - 5, 1=Never, 2=Rarely, 3=Occasionally. 4=Frequently, 5=Always15. I do stretching or flexibility exercises 2 or more times a week.(Required) 1 - Never 2 3 4 5 - Always 16. I do muscle strengthening exercises 2 or more times a week.(Required) 1 - Never 2 3 4 5 - Always 17. I do moderate-intensity aerobic exercise at least 150 minutes (2 hr and 30 minutes) per week.(Required) 1 - Never 2 3 4 5 - Always Physical Health/Nourishment and Weight ManagementPlease rate the following statements from 1 - 5, 1=Never, 2=Rarely, 3=Occasionally. 4=Frequently, 5=Always18. I eat healthy food.(Required) 1 - Never 2 3 4 5 - Always 19. I eat at least 5 servings of fruits and vegetables daily.(Required) 1 - Never 2 3 4 5 - Always 20. I drink 6-8 glasses of water a day.(Required) 1 - Never 2 3 4 5 - Always 21. I eat mindfully (i.e. I pay close attention to the food that I am eating and how it makes me feel.).(Required) 1 - Never 2 3 4 5 - Always 22. I maintain what I consider a healthy weight.(Required) 1 - Never 2 3 4 5 - Always Health ResponsibilityPlease rate the following statements from 1 - 5, 1=Never, 2=Rarely, 3=Occasionally. 4=Frequently, 5=Always23. I can work and do regular activities of daily living.(Required) 1 - Never 2 3 4 5 - Always 24. I avoid smoking (tobacco/nicotine) cigarettes.(Required) 1 - Never 2 3 4 5 - Always 25. I avoid smokeless tobacco.(Required) 1 - Never 2 3 4 5 - Always 26. I avoid consuming alchohol.(Required) 1 - Never 2 3 4 5 - Always 27. I avoid smoking, vaping, or inhaling substances (e.g. marijuana) into my lungs.(Required) 1 - Never 2 3 4 5 - Always 28. I get 7 or more hours of sleep per night.(Required) 1 - Never 2 3 4 5 - Always 29. I know my blood pressure, triglycerides, cholesterol, and glucose levels.(Required) 1 - Never 2 3 4 5 - Always 30. I am aware of my risk factors for disease.(Required) 1 - Never 2 3 4 5 - Always 31. I am able to access health and wellness services that I trust.(Required) 1 - Never 2 3 4 5 - Always 32. I engage in the development of health and wellness plans (i.e. health screenings, medication, supplements, fitness, nutrition, etc.).(Required) 1 - Never 2 3 4 5 - Always 33. I have a primary care physician.(Required) 1 - Never 2 3 4 5 - Always 34. I am able to access dental care when I need it.(Required) 1 - Never 2 3 4 5 - Always 35. I am able to access reliable transportation to/from healthcare appointments.(Required) 1 - Never 2 3 4 5 - Always 36. I am able to take sufficient time away from work to attend healthcare appointments as needed.(Required) 1 - Never 2 3 4 5 - Always 37. I am able to access non-English speaking healthcare providers and services reliably. 1 - Never 2 3 4 5 - Always N/A 38. I have reliable childcare when I need it. 1 - Never 2 3 4 5 - Always N/A Mental HealthPlease rate the following statements from 1 - 5, 1=Never, 2=Rarely, 3=Occasionally. 4=Frequently, 5=Always39. I ask for help when I need it.(Required) 1 - Never 2 3 4 5 - Always 40. I recognize negative thoughts and reframe them.(Required) 1 - Never 2 3 4 5 - Always 41. I can accept circumstances and events beyond my control.(Required) 1 - Never 2 3 4 5 - Always 42. I set realistic goals for myself.(Required) 1 - Never 2 3 4 5 - Always Emotional HealthPlease rate the following statements from 1 - 5, 1=Never, 2=Rarely, 3=Occasionally. 4=Frequently, 5=Always43. I practice forgiveness.(Required) 1 - Never 2 3 4 5 - Always 44. I listen to and respect the feelings of others.(Required) 1 - Never 2 3 4 5 - Always 45. I release unwanted feelings in a healthy way.(Required) 1 - Never 2 3 4 5 - Always Spiritual WellbeingPlease rate the following statements from 1 - 5, 1=Never, 2=Rarely, 3=Occasionally. 4=Frequently, 5=Always46. I feel my life has meaning, value, and purpose.(Required) 1 - Never 2 3 4 5 - Always 47. I feel connected to a force greater than myself.(Required) 1 - Never 2 3 4 5 - Always 48. I make time for reflective practice affirmation, prayer, and/or meditation.(Required) 1 - Never 2 3 4 5 - Always Environmental HealthPlease rate the following statements from 1 - 5, 1=Never, 2=Rarely, 3=Occasionally. 4=Frequently, 5=Always49. My home environment is free of chemical, noise and/or light toxins.(Required) 1 - Never 2 3 4 5 - Always 50. My work environment is free of chemical, noise and/or light toxins.(Required) 1 - Never 2 3 4 5 - Always 51. I am generally aware of the influence of the environment (physical, social, climate, energy patterns) on my health.(Required) 1 - Never 2 3 4 5 - Always RelationshipsPlease rate the following statements from 1 - 5, 1=Never, 2=Rarely, 3=Occasionally. 4=Frequently, 5=Always52. I generally feel like I have a good social support system.(Required) 1 - Never 2 3 4 5 - Always 53. I participate in satisfying relationships.(Required) 1 - Never 2 3 4 5 - Always 54. I feel safe in my existing relationships.(Required) 1 - Never 2 3 4 5 - Always 55. I feel comfortable sharing my feelings/opinion without feeling guilty..(Required) 1 - Never 2 3 4 5 - Always 56. I express my feelings to others in appropriate ways.(Required) 1 - Never 2 3 4 5 - Always 57. I easily express love and concern to those I care about.(Required) 1 - Never 2 3 4 5 - Always Chronic Health Conditions58. From the list below, select all that apply. If none apply, please select "None of the above".(Required) Adrenal Disorders (e.g., Cushing’s syndrome, Addison’s disease) Alzheimer ’s disease Anxiety Disorders Asthma Bipolar Disorder Cardiovascular Diseases Celiac Disease Chronic Back or Body Pain Chronic Fatigue Syndrome (CFS) Chronic Kidney Disease (CKD) Chronic Obstructive Pulmonary Disease (COPD) (e.g., Chronic Bronchitis, Emphysema) Chronic Pain Syndrome Chronic Sinusitis Chronic Urticaria Depression or Mood Disorders Eczema (Atopic Dermatitis) Elevated Cholesterol End-Stage Renal Disease (ESRD) Epilepsy Fibromyalgia Gastroesophageal Reflux Disease (GERD) Heart Disease (including Coronary Artery Disease, Heart Failure, Arrhythmias) Hematologic Cancers (e.g., Leukemia, Lymphoma) Hypertension (High Blood Pressure) Inflammatory Bowel Disease (IBD) (Crohn’s Disease, Ulcerative Colitis) Insomnia Irritable Bowel Syndrome (IBS) Liver Disease (e.g., Cirrhosis, Hepatitis) Lupus Lymphedema Major psychotic/depressive episode in the last year Major Types of Cancer (e.g., Breast, Prostate, Lung, Colorectal, Skin, Pancreatic, Ovarian) Menopause symptoms Metabolic Syndrome Migraine Multiple Sclerosis Obesity Osteoarthritis Osteoporosis Parkinson ’s disease Peripheral Artery Disease Polycystic Ovary Syndrome (PCOS) Post-Traumatic Stress Disorder (PTSD) Prediabetes Psoriasis Restless Leg Syndrome Rheumatoid Arthritis Schizophrenia Sleep Apnea Stroke (Cerebrovascular Disease) Thyroid Disorders (Hypothyroidism, Hyperthyroidism) Type 1 Diabetes Type 2 Diabetes None of the above Other If you selected "Other", please describe Additional Health Information59. Is there any additional information you wish to share?Confidentiality Notice AcknowledgementThe information provided in this form contains protected health information (PHI) protected by federal and state privacy laws. Your PHI will be kept confidential and used solely for authorized purposes. We will share your PHI electronically and use encryption and access controls to safeguard your PHI during transmission and storage. By submitting this form, you acknowledge the collection and use of your PHI as outlined in the Notice of Privacy Policy.60. I consent to the above Confidentiality Notice(Required) Yes No This survey has been adapted from the McElligott D, Turnier J. Integrative health and wellness assessment tool. Crit Care Nurs Clin North Am. 2020;32(3):439-450. More information here.