Form - Stress Assessment

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Stress is a normal part of life. Every day, we’re faced with stimuli, called stressors, which can elicit the body’s “ﬁght or ﬂight” response, setting off a cascade of physiological reactions and resulting in emotions ranging from mild to intense. But while occasional stress is natural and even healthy, chronic or acute stress can be harmful.
Please take a few moments to discover your body’s response to situations you perceive as stressful. By honestly assessing how you feel, your healthcare provider can create a natural stress relief program for your individual needs.
Directions: Please read each statement and choose the number 0, 1, 2, or 3 that best describes your feelings or reactions throughout the course of the day. Determine the subtotal score for each section, then determine the total scores for sections A-C and C-E. 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
Feel driven, appear energetic but feel “burned out” and exhausted
Feel restless, agitated, anxious, and uneasy
Feel easily overwhelmed by emotion
Feel emotional — cry easily or laugh inappropriately
Experience heart palpitations or a pounding in my chest
Am short of breath
Am constipated
Feel warm, over-heated, and dry all over
Get mouth sores or sore tongue
Get hot flashes
Sleep less than seven hours a night
Have trouble falling asleep and staying asleep
Worry about high blood pressure, cholesterol, and triglycerides
Forget to eat and feel little hunger
Section A Total Points*

List your current health problems and any over-the-counter or prescription medications that you are now taking:
Current health problem:
Date of onset:
Month
Day
Year
List all current medications:
Current health problem:
Date of onset:
Month
Day
Year
List all current medications:
Current health problem:
Date of onset:
Month
Day
Year
List all current medications:
I would like to add more to this list
- Yes
Current health problem:
Date of onset:
Month
Day
Year
List all current medications:
Current health problem:
Date of onset:
Month
Day
Year
List all current medications:
Current health problem:
Date of onset:
Month
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List all current medications:
Any last notes?

07. Stress Assessment

Step 1 of 7

Please complete this form in one sitting. Incomplete forms cannot be saved.

Please take a few moments to discover your body’s response to situations you perceive as stressful. By honestly assessing how you feel, your healthcare provider can create a natural stress relief program for your individual needs.

0 = Never true 1 = Seldom true 2 = Sometimes true 3 = Often true

When under stress for two weeks or longer, I… [Section A]

[Section B]

[Section C]

[Section D]

[Section E]

Point Totals

Lifestyle and Health Status

List your current health problems and any over-the-counter or prescription medications that you are now taking:

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