Personal Stress Survey

Name

First NameLast Name

Cell Phone Number*

Area CodePhone Number

Email*

example@example.com

Birth Date

MonthDayYear

Have you experienced any significant life events or changes in the last three months (illness, injury, job change, new baby, marriage, divorce, extreme training for a sporting event, major project at work, etc?

If so, please list:

Do you have any down time to do quiet, relaxing activities? Yoga, Pilates, walking, fishing, gardening, board games, etc.

Type of activity

Hours of restful sleep per night?

2-34-67-88+

Hours of exercise per week?

01-23-56+

Meals eaten out per week?

01-23-56+

Alcoholic drinks per week?

01-23-78+

Stress Survey

	Not much	Little bit	Somewhat	Quite a bit	Very much
1. How stressful would you say your life is?
2. Dealing with daily stress is negatively affecting my daily tasks
3. I eat/drink a lot sugary foods
4. I feel worn down/burnt out
5. I need caffeine or energy drinks in the mornings or afternoons to keep going
6. I seem to have lower energy during the day
7. I have body aches and pains a lot
8. I have periods of low mood or feeling down
9. I feel more irritable
10. My weight and metabolism have changed
11. I can't seem to focus and concentrate like I should
12. I have feelings of anxiousness
13. I feel exhausted most of the day and only have a few productive hours
14. I find myself pushing through fatigue to get things done
15. I sleep but never feel rested when I wake up
16. I have difficulty getting to sleep and wake up in the middle of the night
17.I have strong cravings for sugar and salty foods
18. I feel overwhelmed with my daily tasks, too much on my 'plate'
19. I have a low sex drive
20. I have trouble enjoying socializing w/family friends

Total Score

20-40

Stress is fairly well managed in your life. It may be important to support your body to continue its healthy response.

40-60

Your body’s response to stress may be getting in the way of normal activities quite frequently, leaving you feeling depleted. Consult your health care professional for an individualized program to achieve your health goals.

60-80

You may have experienced prolonged stress, and your body’s stress response can no longer adapt or successfully cope. Consult your health care professional for targeted support and strategies for improvement.

What is the most bothersome thing about your health that you would like fixed?

Main complaint