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Integrative Family Medicine Program

Wellness Assessment and Planning Guide


Physical Activity:
What activities do you really enjoy? (hobbies, sports, recreational, etc.)
Write yourself an exercise prescription (FITT, frequency, intensity, type, timing)

Nutrition:
What’s your relationship with food (healthy, emotional eater, skip meals, etc.)
How many servings of fruits, vegetables daily?
Sources of saturated fat, hydrogenated oils, omega 3 fatty acids?
Sources of protein?  Whole grains?
Home versus work?

Stress/Emotional Health:
What are your top 3 sources of stress?
What do you do to unwind? (read, yoga, exercise, etc.)

Meaning/Spirituality:
Where do you find hope, strength, connectedness?
Where do you find meaning and purpose in your work?

Social and Relational:
Who do you care for?  Who cares for you?
How can you nurture (or repair) these relationships?

Environmental:
Do you live and work in a community that supports your healthy choices?Are you avoiding pollution, unsafe or violent situations?

Family History:
Are there diseases that run in your family that you should be specifically working toward preventing, screening for, etc.?

Sleep: 
Write yourself a prescription for sleep hygiene.

Behaviors/Habits:
Are there any you would like to change? (alcohol, controlled-substances, tobacco, etc.)

Medical:
Do you know your blood pressure, cholesterol level, BMI, etc.?
Have you had appropriate screenings?

Other:
Top 3 goals based on assessment of above that you would like to work on over the next 3 months.
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Strategies for achieving:

Minimum:
Reasonable:
Optimal:

Top 3 goals based on assessment of above that you would like to work on over the next year.
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Strategies for achieving

Minimum:
Reasonable:
Optimal:

Top 3 goals based on assessment of above that you would like to work on over the next 10 years.
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Strategies for achieving

Minimum:
Reasonable:
Optimal:

Review and update quarterly with advisor

 

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Health Information

Maine Medical Center | 22 Bramhall Street | Portland, Maine 04102-3175 | (207) 662-0111