• STRESS & ENERGY PROFILE A short questionnaire about how stress is showing up in your energy, sleep, and body

    Thank you for taking the time to complete this assessment. It takes approximately seven minutes, and there are no right or wrong answers.Your responses are used to prepare a short, easy-to-understand report that explains the stress pattern your answers suggest and what approaches tend to be helpful.This questionnaire is intended for awareness and education only. It is not a diagnosis and is not a plan of care. A questionnaire can help identify patterns, but understanding what is actually going on and determining what may be appropriate for you requires a complete assessment with a licensed naturopathic doctor or other qualified healthcare practitioner.

  • About You

  • Format: (000) 000-0000.
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • What is contributing most? Tick any that apply.

  • The Scale

    Complete the assessment using the 0–3 scale legend: 0 = Never true, 1 = Seldom true, 2 = Sometimes true, 3 = Often true. Read each statement and select the number that best describes how often it is true, not how bad it feels.

  • Energy, Alertness, and Winding Down

  • I get wound up when I get tired and have trouble calming down.*
  • I feel driven, appear energetic but feel "burned out" and exhausted.*
  • I feel restless, agitated, anxious, and uneasy.*
  • I feel easily overwhelmed by emotion.*
  • I experience heart palpitations or pounding in the chest.*
  • I am constipated.*
  • I feel warm, over-heated, and dry all over.*
  • I get mouth sores or sore tongue.*
  • I get hot flashes.*
  • I sleep less than seven hours a night.*
  • I have trouble falling asleep and staying asleep.*
  • I worry about high blood pressure, cholesterol, and triglycerides.*
  • I forget to eat and feel little hunger.*

  • Worry and Racing Thoughts

  • I find myself worrying about things big and small.*
  • I feel impulsive, pent up, and ready to explode.*
  • I get muscle spasms.*
  • I feel aggressive, unyielding, or inflexible when pressed for time.*
  • I see, hear, and smell thing others do not.*
  • I stay awake replaying events of the day or planning for tomorrow.*
  • I have upsetting thoughts or images enter my mind again and again.*
  • I have a hard time stopping myself from doing things again and again, like checking on things and rearranging objects over and over.*

  • Physical Signs

  • I have muscle weakness.*
  • I crave salt, or salty things.*
  • I have dark circles under my eyes.*
  • I feel a sudden sense of anxiety when I get hungry*
  • I get dizzy when rising or standing up from a kneeling or sitting position.*
  • I have diarrhea or bouts of nausea with or without vomiting for no apparent reason.*
  • I have headaches.*

  • Focus, Memory, and Clarity

  • I have trouble organizing my thoughts.*
  • I get easily distracted and lose focus.*
  • I have difficulty making decisions and mistrust my judgement.*
  • I lack the motivation and energy to stay on task and pay attention.*
  • I am forgetful.*
  • I wake up tired and unrefreshed.*
  • I experience heartburn and indigestion.*

  • Rest, Recovery, and Stamina

  • 1. I feel tired for no apparent reason.*
  • 2. I experience lingering mild fatigue after exertion or physical activity.*
  • 4. I feel depressed and apathetic.*
  • 5. I feel cold or chilled - hands, feet, or all over - for no apparent reason.*
  • 6. I have little or no interest in sex.*
  • 7. I sweat spontaneously during the day.*
  • 8. I feel puffy and retain fluids.*
  • 9. I sleep more than nine hours a night.*
  • 11. I have trouble losing weight.*
  • 12. I wake up tired even though I seem to get plenty of sleep.*
  • 14. I am susceptible to colds and the flu.*
  • 15. I feel dragged down by multiple symptoms, such as poor digestion and body aches.*

  • Lifestyle & Health Status

  • Your Health Background

  • Date of onset
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of onset
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of onset
     - -
    2 digit month, 2 digit day, 4 digit year

  • WHAT HAPPENS NEXT

    Dr. Cook reviews your answers and sends you a short report explaining the patterns they point to. If anything in it raises a question, you are welcome to reply and ask.

    If you would like to talk iabout the results, there is a complimenmtary 15 minute discovery calll. If you already know you would like to get started, please book an initial 60 minute appointment online or by callint the clinic at 403-313-4354.

    The goal is to help you feel liike the best version of yourself. Dr. Cook is here and ready to support you in reaching your health goals.

  • Educational use only. The information in this document is for educational purposes only and is not intended for diagnosis, treat, cure, or prevent any disease. It does not replace professional medical advice. Always consult a qualified healthcare provider with questions regarding your health.

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