Make Stress A Thing Of The Past
How well do you think you ar handling stress? This assessment will help you and your health professional design a personalized program to support your stress response and well-being.
Name*
Last*
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:*
Hours of sleep each night*
3-47-85-69+
Hours excercised per week:*
03-51-26+
Alcoholic drinks per week:(1 drink = 12 oz beer, 5 oz wine, 1.5 oz liquor)*
03-71-28+
Meals eaten out per week per week:*
Do you have any downtime or participate in quiet mindfulness activities? (Yoga, meditation, quiet walks, personal hobbies):*
YesNo
Please answer the following questions based on your experience within the last month:
1. How stressful would you say your life is?*
1 - Not at All3 - Somewhat5 - Very Much2 - Little Bit4 - Quite a Bit
2. Dealing with daily stresses is negatively affecting my daily tasks.*
3. I have a high intake of sugar and/or processed foods.*
4. I feel worn down and/or burnt out.*
5. I need caffeine or other energy drinks in the morning or afternoon to give me energy.*
6. I seem to have lower than usual energy during the day.*
7. I experience body aches and pains.*
8. I have periods of low moods.*
9. I feel more irritable.*
10. My weight and metabolism have changed.*
11. I can't seem to focus or concentrate.*
12. I have feelings of anxiousness.*
13. I feel totally 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 seem to be sleeping a lot but never feel quite rested. I wake up feeling tired.*
16. I have difficulty getting to sleep and/or wake up in the middle of the night.*
17. I experience strong cravings for sweet or salty foods.*
18. I feel overwhelmed with daily tasks and all that is on my plate.*
19. I have a low sex drive.*
20. I am unable to enjoy socializing with family and /or friends*label> 1 - Not at All3 - Somewhat5 - Very Much2 - Little Bit4 - Quite a Bit
