Name *

First Name

Last Name

Stress *

Minor problems throw me for a loop.

Often

Sometimes

Rarely

Never

Stress *

I find it difficult to get along with people I used to enjoy.

Often

Sometimes

Rarely

Never

Stress *

Nothing seems to give me pleasure anymore.

Often

Sometimes

Rarely

Never

Stress *

I am unable to stop thinking about my problems.

Often

Sometimes

Rarely

Never

Stress *

I feel frustrated, impatient, or angry much of the time.

Often

Sometimes

Rarely

Never

Stress *

I experience feelings of tension and anxiety.

Often

Sometimes

Rarely

Never

Stress *

During the past month, I have accomplished less than I would like in my work or other daily activities as a result of emotional issues, such as feeling depressed or anxious.

Often

Sometimes

Rarely

Never

Stress *

During the past month, my physical health or emotional issues have interfered with my normal social activities with my normal social activities with family, friends, neighbors, or groups.

Often

Sometimes

Rarely

Never

Stress

I have suffered a personal loss or misfortune in the past year. (For example: a job loss, disability, divorce, separation, or the death of someone close to you.)

Yes

No

Stress *

I am coping well with my current stress load.

Often

Sometimes

Rarely

Never

Feelings *

I feel calm and peaceful.

Often

Sometimes

Rarely

Never

Feelings *

I have a lot of energy.

Often

Sometimes

Rarely

Never

Feelings

I am a happy person.

Often

Sometimes

Rarely

Never

Feelings *

I take the time to relax and have fun daily.

Often

Sometimes

Rarely

Never

Feelings *

I feel downhearted or blue.

Often

Sometimes

Rarely

Never

Feelings *

I feel worthless, inadequate, or unimportant.

Often

Sometimes

Rarely

Never

Sleep *

I get 7-8 hours of sleep at night.

Often

Sometimes

Rarely

Never

Readiness for Change *

My readiness to make changes or improvements in my stress level is (please mark one):

No present interest in making a change

Plan to change in the next 6 months

Plan to change this month

Recently started doing this

Already do this consistently (for more than 6 months)

Confidence *

My confidence in my ability to make a positive change regarding my stress level is:

High

Medium

Low

Priority *

My confidence in my ability to make a positive change regarding my stress level is:

High

Medium

Low

Understanding *

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I understand the above statement and agree to provide this information electronically through this form.