Identi-T Stress Assessment

Identi-T Stress Assessment

Created by Metagenics.
Name

First NameLast Name
I see the following inBalance doctor
Email
example@example.com
Age
Sex

MaleFemaleDecline
Directions: Please read each statement and circle the number 0,1,2,3 that best describes your feelings or reactions throughout the course of the day. Some questions may appear redundant between sections. There's a reason for each question. Don't spend much time on any one question.

0 =Never true

1 =Seldom true

2 =Sometimes true

3 =Often true

When under stress for two weeks or longer, I...

Section A:

Get wound up when I get tired and have trouble calming down

	0	1	2	3

0 is Never True, 3 is Often True

Feel driven, appear energetic but feel "burned out" and exhausted

	0	1	2	3

0 is Never True, 3 is Often True

Feel restless, agitated, anxious, and uneasy

	0	1	2	3

0 is Never True, 3 is Often True

Feel easily overwhelmed by emotion

	0	1	2	3

0 is Never True, 3 is Often True

Feel emotional - cry easily or laugh inappropriately

	0	1	2	3

0 is Never True, 3 is Often True

Experience heart palpitations or a pounding in my chest

	0	1	2	3

0 is Never True, 3 is Often True

Am short of breath

	0	1	2	3

0 is Never True, 3 is Often True

Am constipated

	0	1	2	3

0 is Never True, 3 is Often True

Feel warm, over-heated, and dry all over

	0	1	2	3

0 is Never True, 3 is Often True

Get mouth sores or sore tongue

	0	1	2	3

0 is Never True, 3 is Often True

Get hot flashes

	0	1	2	3

0 is Never True, 3 is Often True

Sleep less than seven hours a night

	0	1	2	3

0 is Never True, 3 is Often True

Have trouble falling asleep and staying asleep

	0	1	2	3

0 is Never True, 3 is Often True

Worry about high blood pressure, cholesterol, and triglycerides

	0	1	2	3

0 is Never True, 3 is Often True

Forget to eat and feel little hunger

	0	1	2	3

0 is Never True, 3 is Often True

Section B:

Find myself worrying about things big and small

	0	1	2	3

0 is Never True, 3 is Often True

Feel like I can't stop worrying, even though I want to

	0	1	2	3

0 is Never True, 3 is Often True

Feel impulsive, pent up, and ready to explode

	0	1	2	3

0 is Never True, 3 is Often True

Get muscle spasms

	0	1	2	3

0 is Never True, 3 is Often True

Feel aggressive, unyielding, or inflexible when pressed for time

	0	1	2	3

0 is Never True, 3 is Often True

See, hear, and smell things that others do not

	0	1	2	3

0 is Never True, 3 is Often True

Stay awake replaying the events of the day or planning for tomorrow

	0	1	2	3

0 is Never True, 3 is Often True

Have upsetting thoughts or images enter my mind again and again

	0	1	2	3

0 is Never True, 3 is Often True

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

0 is Never True, 3 is Often True

Worry a lot about terrible things that could happen if I'm not careful

	0	1	2	3

0 is Never True, 3 is Often True

Section C:

Have muscle and joint pains

	0	1	2	3

0 is Never True, 3 is Often True

Have muscle weakness

	0	1	2	3

0 is Never True, 3 is Often True

Crave salt or salty things

	0	1	2	3

0 is Never True, 3 is Often True

Have multiple points on my body that when touched are tender or painful

	0	1	2	3

0 is Never True, 3 is Often True

Have dark circles under my eyes

	0	1	2	3

0 is Never True, 3 is Often True

Feel a sudden sense of anxiety when I get hungry

	0	1	2	3

0 is Never True, 3 is Often True

Use medications to manage pain

	0	1	2	3

0 is Never True, 3 is Often True

Get dizzy when rising or standing up from a kneeling or sitting position

	0	1	2	3

0 is Never True, 3 is Often True

Have diarrhea or bouts of nausea with or without vomiting for no apparent reason

	0	1	2	3

0 is Never True, 3 is Often True

Have headaches

	0	1	2	3

0 is Never True, 3 is Often True

Section D:

Have trouble organizing my thoughts

	0	1	2	3

0 is Never True, 3 is Often True

Get easily distracted and lose focus

	0	1	2	3

0 is Never True, 3 is Often True

Have difficulty making decisions and mistrust my judgment

	0	1	2	3

0 is Never True, 3 is Often True

Feel depressed and apathetic

	0	1	2	3

0 is Never True, 3 is Often True

Lack the motivation and energy to stay on task and pay attention

	0	1	2	3

0 is Never True, 3 is Often True

Am forgetful

	0	1	2	3

0 is Never True, 3 is Often True

Feel unsettled, restless, and anxious

	0	1	2	3

0 is Never True, 3 is Often True

Wake up tired and unrefreshed

	0	1	2	3

0 is Never True, 3 is Often True

Experience heartburn and indigestion

	0	1	2	3

0 is Never True, 3 is Often True

Catch colds or infections easily

	0	1	2	3

0 is Never True, 3 is Often True

Section E:

Feel tired for no apparent reason

	0	1	2	3

0 is Never True, 3 is Often True

Experience lingering mild fatigue after exertion or physical activity

	0	1	2	3

0 is Never True, 3 is Often True

Find it difficult to concentrate and complete tasks

	0	1	2	3

0 is Never True, 3 is Often True

Feel depressed and apathetic

	0	1	2	3

0 is Never True, 3 is Often True

Feel cold or chilled - hands, feet, or all over - for no apparent reason

	0	1	2	3

0 is Never True, 3 is Often True

Have little or no interest in sex

	0	1	2	3

0 is Never True, 3 is Often True

Sweat spontaneously during the day

	0	1	2	3

0 is Never True, 3 is Often True

Feel puffy and retain fluids

	0	1	2	3

0 is Never True, 3 is Often True

Sleep more than nine hours a night

	0	1	2	3

0 is Never True, 3 is Often True

Have poor muscle tone

	0	1	2	3

0 is Never True, 3 is Often True

Have trouble losing weight

	0	1	2	3

0 is Never True, 3 is Often True

Wake up tired even though I seem to get plenty of sleep

	0	1	2	3

0 is Never True, 3 is Often True

Have no energy and feel physically weak

	0	1	2	3

0 is Never True, 3 is Often True

Am susceptible to colds and the flu

	0	1	2	3

0 is Never True, 3 is Often True

Feel dragged down by multiple symptoms, such as poor digestion and body aches

	0	1	2	3

0 is Never True, 3 is Often True

Lifestyle and Health Status

Click the level of stress you experience on the scale below

	1	2	3	4	5	6	7	8	9	10

1 is None, 10 is Worst

What do you consider to be the major causes of your stress (ex. spouse, family, friends, work, finances, wedding, pregnancy, legal, commute)
How many times a week do you eat breakfast?
What does a typical breakfast look like for you?
How many days a week do you take a multivitamin?
How many days a week do you take a fish oil?
I participate in 30 minutes of physical activity such as walking, aerobis, resistance training, sports, or yoga

Daily5-6x a week3-4x a week1-2x a weekLess than once a week
How many cigarettes do you smoke a day?
I drink two or more 8 ounce cups of caffeinated coffee or other caffeinated beverages such as energy/diet drinks, colas, or black/green teas:

Daily5-6x a week3-4x a week1-2x a weekLess than once a week
I drink two or more ounces of alcoholic beverages:

Daily5-6x a week3-4x a week1-2x a weekLess than once a week
I have the following health problems:
I take the following over-the-counter and prescription medications
Should be Empty: