Nervous System Assessment

Name*

First NameLast Name

Email*

example@example.com

How do you typically feel throughout the day?*

	Choose 1
I often feel numb or disconnected from my surroundings
I frequently feel tense and on edge, like I need to be constantly alert
I generally feel relaxed, engaged, and connected with others
It's a combination of them all but typically bounce back and forth between 1 and 2

Do you often feel calm and at ease, or do you frequently experience stress and anxiety?*

	Choose 1
I struggle to feel any emotions and often feel like I'm in a fog
I often experience high levels of stress and anxiety, feeling like I'm in a constant state of urgency
I usually feel calm, at ease, and able to handle life's challenges
It's a combination of them all but typically bounce back and forth between 1 and 2

Do you experience any physical symptoms such as rapid heartbeat, shortness of breath, or muscle tension?*

	Choose 1
I often feel physically numb or disconnected and don't notice such symptoms
I frequently experience rapid heartbeat, shortness of breath, and muscle tension.
I rarely experience these physical symptoms and generally feel physically at ease
It's a combination of them all but typically bounce back and forth between 1 and 2

Have you noticed any changes in your sleep patterns, such as difficulty falling asleep, staying asleep, or waking up feeling rested?*

	Choose 1
I often sleep a lot but still wake up feeling unrefreshed
I have trouble falling asleep, staying asleep, and often wake up feeling anxious
I generally have a good sleep pattern and wake up feeling rested
It's a combination of them all but typically bounce back and forth between 1 and 2

Do you often feel physically fatigued or exhausted, even after a full night's sleep?*

	Choose 1
I frequently feel exhausted and lethargic, regardless of how much sleep I get
I sometimes feel restless and have trouble relaxing, leading to fatigue
I usually feel refreshed and energetic after a good night's sleep
It's a combination of them all but typically bounce back and forth between 1 and 2

How do you usually respond to stressful situations? Do you feel overwhelmed, anxious, or panicked?*

	Choose 1
I tend to shut down and feel disconnected, like I can't handle the situation
I often feel overwhelmed, anxious, or panicked and find it hard to think clearly
I generally stay calm and try to manage the situation effectively
It's a combination of them all but typically bounce back and forth between 1 and 2

Do you find yourself feeling numb, detached, or emotionally disconnected?*

	Choose 1
Yes, I frequently feel numb, detached, or emotionally disconnected
No, I tend to feel more anxious and hyper-alert rather than numb
No, I usually feel emotionally connected and engaged
It's a combination of them all but typically bounce back and forth between 1 and 2

Are there times when you feel unusually irritable, angry, or easily triggered?*

	Choose 1
Not really, I more often feel detached and unresponsive
Yes, I frequently feel irritable, angry, or easily triggered
No, I generally maintain a balanced and calm demeanor
It's a combination of them all but typically bounce back and forth between 1 and 2

Do you tend to avoid certain situations or people due to anxiety or stress?*

	Choose 1
Yes, I often avoid situations or people because I feel overwhelmed and shut down
Yes, I frequently avoid situations or people because they make me anxious or stressed
No, I generally feel comfortable and able to handle most situations and people
It's a combination of them all but typically bounce back and forth between 1 and 2

Do you often feel a strong need to stay busy or distracted?*

	Choose 1
No, I often feel disengaged and lack motivation to do anything
Yes, I frequently feel the need to stay busy or distracted to manage my anxiety
No, I feel balanced and do not have an overwhelming need to stay busy or distracted
It's a combination of them all but typically bounce back and forth between 1 and 2

Have you noticed any patterns of procrastination or difficulty in focusing on tasks?*

	Choose 1
Yes, I often procrastinate and have trouble focusing because I feel disconnected and unmotivated
Yes, I sometimes procrastinate or struggle to focus because I feel anxious and restless
No, I usually can focus well and complete tasks without procrastinating
It's a combination of them all but typically bounce back and forth between 1 and 2

What strategies do you use to cope with stress or anxiety? Are these strategies effective?*

	Choose 1
I often withdraw and try to shut out everything, but it doesn't seem to help much
I try to stay busy or distract myself, but it sometimes just makes me feel more stressed
I use techniques like deep breathing, mindfulness, or talking to someone, and they usually help me feel better
It's a combination of them all but typically bounce back and forth between 1 and 2

Do you engage in any practices such as deep breathing, meditation, or exercise to help regulate your emotions and stress levels?*

	Choose 1
No, I usually don't feel motivated or inspired to engage in these practices
I try, but I find it hard to stick with these practices regularly
Yes, I regularly practice deep breathing, meditation, or exercise, and it helps me a lot
It's a combination of them all but typically bounce back and forth between 1 and 2

How often do you find time for activities that you enjoy and that help you relax?*

	Choose 1
Rarely, I often feel too disconnected or uninterested to do activities I enjoy
Sometimes, but I often feel too anxious or busy to truly relax and enjoy them
Frequently, I make it a priority to engage in activities that help me relax and feel happy
It's a combination of them all but typically bounce back and forth between 1 and 2

How would you describe your overall level of energy and motivation?*

	Choose 1
I often feel low on energy and lack motivation to do anything
I frequently feel restless and hyper, but my energy is often driven by anxiety
I generally have a good level of energy and feel motivated to take on tasks
It's a combination of them all but typically bounce back and forth between 1 and 2

Do you feel in control of your emotions and reactions, or do they often feel unpredictable?*

	Choose 1
I usually feel emotionally numb or detached, and it's hard to gauge my reactions
My emotions often feel intense and unpredictable, making it hard to stay in control
I typically feel in control of my emotions and can respond to situations calmly
It's a combination of them all but typically bounce back and forth between 1 and 2

How aware are you of the connection between your mind and body, particularly in stressful situations?*

	Choose 1
I often feel disconnected from my body and not very aware of the mind-body connection
I am acutely aware of my body's reactions during stress, often feeling overwhelmed by them
I have a good awareness of how my mind and body interact, especially during stress, and can manage this connection well
It's a combination of them all but typically bounce back and forth between 1 and 2

Dorsal Shutdown Count

Sympathetic Fight or Flight Count

Ventral Vagal Count

Dysregulated Count

It's important you select only 1 answer per question!