Stress Assessment Form

Stress Assessment Form

How are you feeling?
Assessing the Stressors in Your Life

This assessment will help you gain a perspective on your emotional health. You and Dr. Brown can use this information to design a personal program that supports your stress response and well being.
Date

MonthDayYear
Date
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Have you experienced any significant life events or change in the last year.

IllnessInjuryJob changeNew babyMarriageDivorceExtreme training for a sporting eventMajor projects at workHead TraumaSurgeryStressorsMoveOther
How many Hours of Sleep each night do you get?
How many Hours do you Exercise per week?
How many Meals eaten out per week?
How many Alcoholic drinks do you have per week?
Do you have any Downtime or participate in quite Mindfulness activity?

Yoga, pilatesMeditationQuite walksPersonal hobbiesOther

Please answer the following questions based on your experience within the month. Click the circle below from 2 to 5. Your score will be added up below. Leave the circle BLANK if it does not apply to you.

	2 A little bit	3 Somewhat	4 Quite a bit	5 Very much
How stressful would you say your life is?
I have a high intake of sugar and processes foods.
Dealing with stressors are negatively affecting my daily tasks.
I fell worn down and burned out.
I need caffeine or other energy drinks in the morning or afternoon
I seem to have lower energy during the day.
I experience body aches and pains.
I have periods of low moods
I feel more irritable.
My weight and metabolism have changed.
I can't seem to focus or concentrate.
I have feeling of anxiousness.
I feel totally exhausted most of the day and only have a few productive hours.
I find myself pushing through fatigue to get things done.
I seem to be sleeping a lot but never feel quite rested. I awake feeling tired.
I have difficulties getting to sleep at night.
I wake up a lot at night.
I have a strong craving for sugary foods.
I have strong craving for salty foods.
I feel overwhelmed with my daily tasks and all that is on my plate.
I have a low sex drive.
I am unable to enjoy socializing with friends and/or family.

Total score to determine where you fall on the stress scale below.
Review your Score Below. It indicates your level of stress and where you may want to receive support.

Score 0-35 Low-Stress Level

Stress a relatively well managed in life; It may be essential to support your body to continue its healthy response.

Score 35-65 Moderate Stress Level

Your body’s response to stress may get in the way of everyday activities quite frequently, leaving you feeling depleted. Consult with Dr. Keri Brown for an individualized program to achieve your health goals.

Score 65-100 High Stress Level

You may have experienced prolonged stress, and your body’s stress response can no longer adapt to cope successfully. Consult with Dr. Keri Brown for targeted support and strategies for improvement.
Contact us at 719-423-0306 for support and to consult with Dr. Keri Brown about your Stress Assessment.
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Stress Assessment Form

Assessing the Stressors in Your Life