Holistic Health Assessment
There are 7 sections to this survey which include questions about your physical, emotional, social, spiritual, intellectual, cultural and financial identity. A score will be calculated based on your responses and emailed to you.

Please be as honest as possible to ensure you grow and gain as much from this opportunity as possible.

Congratulations for embarking on this healing journey!
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Email *
First & last name *
Age *
Education level *
*
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1=Almost Never
2=Occasionally
3=Often
4=Very Often
5=Almost Always
1. Do you eat at least 5 servings of fresh fruits and vegetables daily (one serving equals one piece of fruit or 1/2 cup of vegetables)
2. Do you take supplements to compensate for a food supply that is depleted in vitamins and nutrients?
3. Do you drink water (at least ½ oz./lb. of body weight; 160 lbs. = 80 oz. “10 cups” per day)?
4. Do you engage in regular sweat-producing physical exercise lasting at least 20 minutes, 5 days a week?
5. Are you within 10 pounds of your ideal body weight?
6. Are you free of chronic aches, pains, ailments and diseases?
7. Do you fall asleep easily, sleep soundly for at least 6 hours every night and awake feeling refreshed?
8. Do you have more than enough energy to meet your daily responsibilities?
9. Do listen to your body? And when there is something wrong, do you seek professional advice?
10. Do you know your important health numbers: cholesterol, blood pressure, blood glucose, body weight, etc.?
*
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1=Almost Never
2=Occasionally
3=Often
4=Very Often
5=Almost Always
1. I am able to effectively deal with the day-to-day pressures.
2. I know how to set and reach goals and objectives.
3. I have read a non-fiction book (not for class) in the past six months.
4. I pursue mentally stimulating interests or hobbies.
5. I commit time and energy to professional and self-development.
6. I maintain balance of work, family, friends, and other obligations.
7. I balance work with play and other aspects of my life.
8. If I see a safety hazard, I take the steps to fix the problem.
9. I take time to appreciate nature.
10. I visualize my current career as a real means to contribute to society.
*
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1=Almost Never
2=Occasionally
3=Often
4=Very Often
5=Almost Always
1. Do you or did you feel close to your parents and immediate family?
2. Do you confide in and feel understood by your friends, your colleagues and your doctor?
3. Do you experience intimacy, besides sex, in your committed relationships?
4. Are you a part of any larger communities where you get a lot out of being part of the community?
5. Do you feel your role in the community is known and recognized?
6. Do you feel safe and have a strong sense of belonging in your home and neighboring environment?
7. Do you have a good working idea about how marriage, family, and career fit together?
8. Do you have at least three people with whom you have a close trusting relationship?
9. Do you participate in a wide variety of social activities and find opportunities to form new relationships?
10. Do you believe you are expanding your knowledge about your entire well-being on a regular and consistent basis?
*
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1=Almost Never
2=Occasionally
3=Often
4=Very Often
5=Almost Always
1. Do you feel joy, hope and happiness more often than sadness, despair and jealousy?
2. Do you feel able to safely and comfortably express your true emotions including allowing yourself to cry?
3. Are you largely free of shame, regret or guilt about your past?
4. Do you take time for prayer, meditation, or reflection?
5. Do you listen to your intuition / spirit?
6. Do you feel an overall sense of peace within yourself?
7. I do not let my emotions get the better of me and I think before I act.
8. Are you able to recognize the stressors in your life and take steps to manage your stress (e.g., exercise, quiet time, meditation)
9. When you are angry, you try to let others know in non-confrontational or non-hurtful ways
10. Are you able to assert yourself when necessary?
*
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1=Almost Never
2=Occasionally
3=Often
4=Very Often
5=Almost Always
1. Are you able to value the different and potentially opposing perspectives of others?
2. Do you feel free from discrimination or scorn based on your race, sex or creed?
3. Do you feel satisfied with your knowledge of your African ancestry?
4. Are you able to collaborate and congregation with your cousins in Africa?
5. Do you engage in discussions about cultural issues and work towards resolutions on a regular basis?
6. Do have a positive image of your ethnic pride?
7. Are you able to tell me about the traditions/celebrations/rituals your ancestors participated in?
8. Are you currently able to tell me about the spiritual practices your ancestors participated in?
9. Do you feel respect and proud of your race?
10. Do you feel you are currently utilizing all of your greatest talents and gifts?
*
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1=Almost Never
2=Occasionally
3=Often
4=Very Often
5=Almost Always
1. Do you feel satisfied with your religion/spirituality?
2. Do you make attempts to expand your awareness of different ethnic, racial, and religious groups?
3. Do you have a sense of belonging/not being isolated?
4. Do you have rock solid faith in a higher power?
5. Do you spend time outdoors enjoying nature?
6. Do you integrate my "spiritual practice" within everyday life of work, family and relationships?
7. Do you take time to think about what’s important in life – who I am, what I value, where I fit in, and where I am going
8. Have you found a balance between meeting your needs and those of others?
9. Do you grow personally or spiritually from pain and suffering you experience?
10. Do you feel like your life has a positive purpose, meaning and direction?
*
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1=Almost Never
2=Occasionally
3=Often
4=Very Often
5=Almost Always
1. Do you have a solid balance between saving for the future and spending for the present?
2. Do you always have the money for what you need?
3. Do you track your spending to stay within a personal and family budget?
4. Do you feel at peace when you think about your finances?
5. Do you have the disposable income for the vacations and leisure activities you desire?
6. Do you feel that if anything were to happen to you today; you could leave a sizeable inheritance (house, money, land, etc.…) to your children?
7. Are you happy with your credit score? i.e. it’s above average
8. Do you feel free from debt (student loans, mortgages, credit cards, medical debt, vehicle and personal loans, etc.)?
9. Do you have access to reliable business opportunities that with time and work can manifest into a reliable cash influx?
10. Have you adopted water saving habits (i.e., I try not to leave the faucet running too long when I wash dishes, brush my teeth, shave, or bathe)?
A copy of your responses will be emailed to the address you provided.
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