Patient Stress Questionnaire
Please answer all questions
honestly
; your answers will be kept
confidential
.
Name:
*
First Name
Last Name
Gender:
*
Female
Male
Date of Birth:
*
-
Month
-
Day
Year
Date
Age:
*
School:
*
Berkeley Springs High School
Paw Paw Elementary School
Paw Paw High School
Warm Springs Middle School
Grade Level:
*
6th
7th
8th
9th
10th
11th
12th
Today's Date:
*
-
Month
-
Day
Year
Date
Over the last two weeks, how often have you been bothered by any of the following problems?
*
Not at all
Several days
More than half the days
Nearly everyday
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep
Sleeping too much
Feeling tired or having little energy
Poor appetite
Overeating
Feeling bad about yourself or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people have noticed
Being so fidgety or restless that you've been moving around a lot more than usual
Thoughts that you would be better off dead
Hurting yourself in some way
*
Not at all
Several days
More than half the days
Nearly everyday
Feeling nervous, anxious or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen
Are you currently in any physical pain?
*
Yes
No
In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you:
*
No
Yes
1. Have had nightmares about it or thought about it when you did not want to?
2. Tried hard not to think about it or went out of way to avoid situations that reminded you of it?
3. Were constantly on guard, watchful, or easily startled?
4. Felt numb or detached from others, activities, or your surroundings?
Submit
Should be Empty: