Patient Stress Questionnaire
20-minute duration test. Over the last 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things
*
Not at all
Several days
More than half the days
Nearly everyday
Feeling down, depressed, or hopeless
*
Not at all
Several days
More than half the days
Nearly everyday
Trouble falling or staying asleep, or sleeping too much
*
Not at all
Several days
More than half the days
Nearly everyday
Feeling tired or having little energy
*
Not at all
Several days
More than half the days
Nearly everyday
Poor appetite or overeating
*
Not at all
Several days
More than half the days
Nearly everyday
Feeling bad about yourself or that you are a failure or have let yourself or your family down
*
Not at all
Several days
More than half the days
Nearly everyday
Trouble concentrating on things, such as reading the newspaper or watching television
*
Not at all
Several days
More than half the days
Nearly everyday
Moving or speaking so slowly that other people could have noticed, or the opposite - being so fidgety or restless that you've been moving around a lot more than usual
*
Not at all
Several days
More than half the days
Nearly everyday
Thoughts that you would be better off dead, or hurting yourself in some way
*
Not at all
Several days
More than half the days
Nearly everyday
Feeling nervous, anxious or on edge
*
Not at all
Several days
More than half the days
Nearly everyday
Not being able to stop or control worrying
*
Not at all
Several days
More than half the days
Nearly everyday
Worrying too much about different things
*
Not at all
Several days
More than half the days
Nearly everyday
Trouble relaxing
*
Not at all
Several days
More than half the days
Nearly everyday
Being so restless that it is hard to sit still
*
Not at all
Several days
More than half the days
Nearly everyday
Becoming easily annoyed or irritable
*
Not at all
Several days
More than half the days
Nearly everyday
Feeling afraid as if something awful might happen
*
Not at all
Several days
More than half the days
Nearly everyday
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Next
Are you currently in any physical pain?
*
Yes
No
In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you...
Have had nightmares about it or thought about it when you did not want to?
*
Yes
No
Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
*
Yes
No
Were constantly on guard, watchful, or easily startled?
*
Yes
No
Felt numb or detached from others, activities, or your surroundings?
*
Yes
No
Back
Next
How often do you have a drink containing alcohol?
*
Never
Monthly or less
2-4 times a month
2-3 times a week
4+ times a week
How many drinks containing alcohol do you have on a typical day when you are drinking?
*
0-2
3-4
5-6
7-9
10+
How often do you have four or more drinks on one occasion?
*
Never
Less than monthly
Monthly
Weekly
Daily/Almost Daily
How often during the last year have you……
…found that you were not able to stop drinking once you had started?
*
Never
Less than monthly
Monthly
Weekly
Daily/Almost Daily
…failed to do what was normally expected from you because of drinking?
*
Never
Less than monthly
Monthly
Weekly
Daily/Almost Daily
…needed a first drink in the morning to get yourself going after heavy drinking?
*
Never
Less than monthly
Monthly
Weekly
Daily/Almost Daily
…had a feeling of guilt or remorse after drinking?
*
Never
Less than monthly
Monthly
Weekly
Daily/Almost Daily
…been unable to remember what happened the night before because you had been drinking?
*
Never
Less than monthly
Monthly
Weekly
Daily/Almost Daily
…been unable to remember what happened the night before because you had been drinking?
*
Never
Less than monthly
Monthly
Weekly
Daily/Almost Daily
Have you or someone else been injured as a result of your drinking?
*
No
Yes, but not in the last year
Yes, during the last year
Has a relative, friend, doctor or other health worker been concerned about your drinking or suggested you cut down?
*
No
Yes, but not in the last year
Yes, during the last year
Name
*
First Name
Last Name
Email
*
example@example.com
Calculation
Submit
Should be Empty: