Stress Solutions of New York

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:*

03-51-26+

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:

5. I need caffeine or other energy drinks in the morning or afternoon to give me energy.*

1 - Not at All3 - Somewhat5 - Very Much2 - Little Bit4 - Quite a Bit

13. I feel totally exhausted most of the day and only have a few productive hours.*

1 - Not at All3 - Somewhat5 - Very Much2 - Little Bit4 - Quite a Bit

15. I seem to be sleeping a lot but never feel quite rested. I wake up feeling tired.*

1 - Not at All3 - Somewhat5 - Very Much2 - Little Bit4 - Quite a Bit

16. I have difficulty getting to sleep and/or wake up in the middle of the night.*

1 - Not at All3 - Somewhat5 - Very Much2 - Little Bit4 - Quite a Bit

STRESS ASSESS

STANDARD PROCESS STRESS ASSESS