Stress Assess

Date*

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 changes in the last three months (illness, injury, job change, new baby, marriage, divorce, extreme training for sporting event, major project at work, ect.)? If so, please list. If no, write NA: blanks*

Hours of Sleep Each Night*

3-45-67-89+

Hours exercised per week*

01-23-56+

Alcoholic drinks per week*

01-23-78+

Meals eaten out per week*

01-23-56+

Do you have any downtime or participate in quiet mindfulness activities? (Pilates, yoga, meditation, quiet walks, personal hobbies YES NO *

Please answer the following questions based on your experience within the LAST MONTH.*

	Not at All	Little Bit	Somewhat	Quite a Bit	Very Much
How stressful would you say your life is?
Dealing with daily stresses is negatively affecting my daily tasks.
I have a high intake of sugar and/or processed foods.
I feel worn down and/or burnt out.
I need caffeine or other energy drinks in the morning or afternoon to give me energy.
I seem to have lower than usual 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 feelings 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 better but never feel quite rested. I wake up feeling tired.
I have difficulty getting to sleep and/or wake up in the middle of the night.
I experience strong cravings for sweet or salty foods.
I feel overwhelmed with daily tasks and all that is on my plate.
I have a low sex drive.
I am able to enjoy socializing with friends and/or family.

Total Score