HPA Questionnaire Stress and Mental Health

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Email

example@example.com

todays date

MonthDayYear

Group 1

Rows	never	sometimes	often	frequent
afternoon or evening cravings
negativity/depression
worry/anxiety
low self esteem
obsessive thoughts behaviors
hyperactivity
controlling
perfectionism
irritability/rage
panic attack
fibromyalgia/pain
phobias
suicidal thoughts
insomnia
night owl behavior

Group 2

Rows	never	sometimes	often	frequent
Craving for stimultion from sugar chocolate, caffeine
depression/apathy
lack of energy
lack of drive
easily bored
lack of concentration
ADD

Group 3

Rows	never	sometimes	often	frequent
carving carbs and/or alcohol for relaxation
stressed and burned out
unable to relax/loosen up
stiff or tense muscles
easily overwhelmed

Group 4

Rows	never	sometimes	often	frequent
seeking comfort foods, treats
"Love" certain foods or behaviors
sensitive to emotional or physical pain
Cry and/or tear up easily

Group 5

Rows	never	sometimes	often	frequent
crave carbs, starch, alcohol
irritable, shaky, headachey if to0 long between meals

Part II

Type A

Rows	never	sometimes	often	frequent
Get wound up when I get tired and have trouble calming down.
Feel driven, appear energetic but feel “burned out” and exhausted.
Feel restless, agitated, anxious, and uneasy.
Feel easily overwhelmed by emotion.
Feel emotional — cry easily or laugh inappropriately
Experience heart palpitations or a pounding in my chest.
Am short of breath
Am constipated.
Feel warm, over-heated, and dry all over.
Get mouth sores or sore tongue.
Get hot flashes.
Sleep less than seven hours a night
Have trouble falling asleep and staying asleep.
Worry about high blood pressure, cholesterol, and triglycerides.
Forget to eat and feel little hunger

type B

Rows	never	sometimes	often	frequent
Find myself worrying about things big and small
Feel like I can’t stop worrying, even though I want to.
Feel impulsive, pent up, and ready to explode.
Get muscle spasms.
Feel aggressive, unyielding, or inflexible when pressed for time.
See, hear, and smell things that others do not.
Stay awake replaying the events of the day or planning for tomorrow.
Have upsetting thoughts or images enter my mind again and again
Have a hard time stopping myself from doing things again and again, like checking on things or rearranging objects over and over
Worry a lot about terrible things that could happen if I’m not careful.

section c

Rows	never	sometimes	often	frequent
Have muscle and joint pains
Have muscle weakness
Crave salt or salty things
Have multiple points on my body that when touched are tender or painful
Have dark circles under my eyes
Feel a sudden sense of anxiety when I get hungry
Use medications to manage pain
Get dizzy when rising or standing up from a kneeling or sitting position
Have diarrhea or bouts of nausea with or without vomiting for no apparent reason
Have headaches

section D

Rows	never	sometimes	often	frequent
Have trouble organizing my thoughts.
Get easily distracted and lose focus.
Have difficulty making decisions and mistrust my judgment.
Feel depressed and apathetic
Lack the motivation and energy to stay on task and pay attention.
Am forgetful
Feel unsettled, restless, and anxious
Wake up tired and un-refreshed
Experience heartburn and indigestion
Catch colds or infections easily

Section E

Rows	never	sometimes	often	frequent
Feel tired for no apparent reason
Experience lingering mild fatigue after exertion or physical activity
Find it difficult to concentrate and complete tasks
Feel depressed and apathetic
Feel cold or chilled – hands, feet, or all over – for no apparent reason
Have little or no interest in sex.
Sweat spontaneously during the day
Feel puffy and retain fluids
Sleep more than nine hours a night
Have poor muscle tone
Have trouble losing weight
Wake up tired even though I seem to get plenty of sleep
Have no energy and feel physically weak
Am susceptible to colds and the flu
Feel dragged down by multiple symptoms, such as poor digestion and body aches

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HPA Questionnaire Stress and Mood Assessment