Patient Stress Questionnaire

Please answer all questions honestly; your answers will be kept confidential.

Name:*

First NameLast Name

FemaleMale

Date of Birth:*

Date

Age:*

School:*

Grade Level:*

Today's Date:*

Date

Over the last two weeks, how often have you been bothered by any of the following problems? *

Rows	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

Rows	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

YesNo

In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you:*

Rows	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?