Stress Questionnaire

Name*

First NameLast Name

Date

MonthDayYear

Email*

example@example.com

Day-to-day experiences

Below is a collection of statements about your everyday experience.
Using the 1-6 scale, please indicate how frequently or infrequently you currently have each experience.
Please answer according to what really reflects your experience rather than what you think your experience should be.
Treat each item separately from every other item.

1 = Almost Always 2 = Very Frequently 3 = Somewhat Frequently 4 = Somewhat Infrequently 5 = Very Infrequently 6 = Almost Never*

	1	2	3	4	5	6
1. I could be experiencing some emotion and not be conscious of it until some time later
2. I break or spill things because of carelessness, not paying attention, or thinking of something else
3. I find it difficult to stay focused on what’s happening in the present
4. I tend to walk quickly to get where I’m going without paying attention to what I experience along the way
5. I tend not to notice feelings of physical tension or discomfort until they really grab my attention
6. I forget a person’s name almost as soon as I’ve been told it for the first time
7. It seems I am “running on automatic,” without much awareness of what I’m doing
8. I rush through activities without being really attentive to them
9. I get so focused on the goal I want to achieve that I lose touch with what I’m doing right now to get there
10. I do jobs or tasks automatically, without being aware of what I’m doing
11. I find myself listening to someone with one ear, doing something else at the same time
12. I drive to places on ‘automatic pilot’ and then wonder why I went there
13. I find myself preoccupied with the future or the past
14. I find myself doing things without paying attention
15. I snack without being aware of what I’m eating

Perceived Stress Scale

The questions in this scale ask you about your feelings and thoughts during the last month.
In each case, you will be asked to indicate how often you felt or thought a certain way.

0 = Never 1 = Almost Never 2 = Sometimes 3 = Fairly Often 4 = Very Often*

	0	1	2	3	4
1. In the last month, how often have you been upset because of something that happened unexpectedly?
2. In the last month, how often have you felt that you were unable to control the important things in your life?
3. In the last month, how often have you felt nervous and “stressed”?
4. In the last month, how often have you felt confident about your ability to handle your personal problems?
5. In the last month, how often have you felt that things were going your way?
6. In the last month, how often have you found that you could not cope with all the things that you had to do?
7. In the last month, how often have you been able to control the irritations in your life?
8. In the last month, how often have you felt that you were on top of things?
9. In the last month, how often have you been angered because of things that were outside of your control?
10. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?

Emotional Regulation Scale

We would like to ask you some questions about your emotional life, in particular, how you control (that is, regulate and manage) your emotions. The questions below involve two distinct aspects of your emotional life.
One is your emotional experience, or what you feel like inside. The other is your emotional expression, or how you show your emotions in the way you talk, gesture, or behave.
Although some of the following questions may seem similar to one another, they differ in important ways.

1 = Strongly Agree 4 = Neutral 7 = Strongly Disagree*

	1	2	3	4	5	6	7
1. When I want to feel more positive emotion (such as joy or amusement), I change what I’m thinking about
2. I keep my emotions to myself
3. When I want to feel less negative emotion (such as sadness or anger), I change what I’m thinking about
4. When I am feeling positive emotions, I am careful not to express them
5. When I’m faced with a stressful situation, I make myself think about it in a way that helps me stay calm
6. I control my emotions by not expressing them
7. When I want to feel more positive emotion, I change the way I’m thinking about the situation
8. I control my emotions by changing the way I think about the situation I’m in
9. When I’m feeling negative emotions, I make sure not to express them
10. When I want to feel less negative emotion, I change the way I’m thinking about the situation

Stress Questionnaire - Mindfulness Training Institute