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STRESS ASSESSMENT

Date

Please take a few moments to discover your body’s response to situations you perceive as stressful.


Please read each statement and tick the number that best describes your feelings or reactions over the past 2 weeks or longer. Don’t spend too much time on any one question and become aware if you tend to exaggerate or underplay certain symptoms. Be as honest as possible, as your answers will determine your stress management plan.

0 = Never 1= Hardly 2= Sometimes 3= All the time

When under stress for two weeks or longer, I…

WIRED PHYSICAL STRESS

Get wound up when I get tired and have trouble calming down
0
1
2
3
Feel driven, appear energetic but feel “burned out” and exhausted
0
1
2
3
Feel restless, agitated, anxious, and uneasy
0
1
2
3
Feel easily overwhelmed by emotions
0
1
2
3
Cry too easily or laugh inappropriately
0
1
2
3
Experience heart palpitations or a pounding in my chest
0
1
2
3
Am short of breath for no apparent reason
0
1
2
3
Tend to be constipated
0
1
2
3
Feel warm, over-heated, and dry all over - not related to menopause
0
1
2
3
Get mouth sores or sore tongue
0
1
2
3
Get hot flushes not related to menopause
0
1
2
3
Sleep less than seven hours a night because of stress
0
1
2
3
Have trouble falling asleep and staying asleep
0
1
2
3
At risk of or have high blood pressure or high cholesterol
0
1
2
3
Forget to eat and feel little hunger
0
1
2
3

WORRIED MENTAL STRESS

Find myself worrying about small things unnecessarily
0
1
2
3
Feel like I can’t stop worrying, even though I want to
0
1
2
3
Feel impulsive, pent up, and ready to explode
0
1
2
3
Get muscle spasms and muscle pain
0
1
2
3
Feel aggressive, unyielding, or inflexible when pressed for time
0
1
2
3
See and hear things that aren't there
0
1
2
3
Stay awake replaying the events of the day or planning for tomorrow
0
1
2
3
Have upsetting thoughts or images enter my mind again and again
0
1
2
3
Have a hard time stopping myself from doing things again and again, like checking on things or rearranging objects over and over.
0
1
2
3
Worry a lot about terrible things that could happen if I’m not careful
0
1
2
3

INFLAMED STRESS

Have muscle and joint pains not related to injury
0
1
2
3
Have muscle weakness
0
1
2
3
Crave salty things
0
1
2
3
Have multiple points on my body that when touched are tender or painful
0
1
2
3
Have dark circles under my eyes
0
1
2
3
Feel a sudden sense of anxiety when I get hungry
0
1
2
3
Use medications to manage pain
0
1
2
3
Have low blood pressure i.e. get dizzy when sitting or standing up too fast
0
1
2
3
Have diarrhea or bouts of nausea with or without vomiting for no apparent reason
0
1
2
3

MENTAL FATIGUE AND BURNOUT

Have trouble organizing my thoughts
0
1
2
3
Get easily distracted and lose focus
0
1
2
3
Have difficulty making decisions and mistrust my judgment
0
1
2
3
Feel depressed and apathetic
0
1
2
3
Lack the motivation and energy to stay on task and pay attention
0
1
2
3
Am forgetful
0
1
2
3
Feel unsettled, restless, and anxious
0
1
2
3
Wake up tired and unrefreshed
0
1
2
3
Experience heartburn and indigestion
0
1
2
3
Am susceptible to colds and the flu
0
1
2
3
Am susceptible to colds and the flu
0
1
2
3

PHYSICAL FATIGUE AND BURNOUT

Feel tired for no apparent reason
0
1
2
3
Experience lingering mild fatigue after exertion or physical activity
0
1
2
3
Find it difficult to concentrate and complete tasks
0
1
2
3
Feel depressed and apathetic
0
1
2
3
Feel cold or chilled – hands, feet, or all over – for no apparent reason
0
1
2
3
Have little or no interest in sex
0
1
2
3
Sweat spontaneously during the day not related to menopause
0
1
2
3
Feel puffy and retain fluids
0
1
2
3
Sleep more than nine hours a night
0
1
2
3
Have poor muscle tone
0
1
2
3
Have trouble losing weight
0
1
2
3
Wake up tired even though I seem to get plenty of sleep
0
1
2
3
Have no energy and feel physically weak
0
1
2
3
Am susceptible to colds and the flu
0
1
2
3
Feel dragged down by multiple symptoms, such as poor digestion and body aches
0
1
2
3
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