Stress Indicator

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The Counseling Team International 1881 Business Center Drive, Suite 11 San Bernardino, CA 92408 (909) 884-0133 www.thecounselingteam.com

STRESS INDICATORS QUESTIONNAIRE
This questionnaire will show how stress affects different parts of your life. Circle the response which best indicates how often you experience each stress indicator during a typical week. When you have answered all the questions add the point totals for each section. 5- Almost Always (on five days a week) 4- Most of the time (on three days a week) 3- Some of the time ( on one and one-half days a week) 2- Almost never (less than two hours a week) 1- Never PHYSICAL INDICATORS: How often would you say: Most Some Almost of the of the Almost always time time never Never

My body feels tense all over. I have a nervous sweat or sweaty palms. I have a hard time feeling really relaxed. I have severe or chronic lower back pain. I get severe or chronic headaches. I get tension or muscle spasms in my face, jaw, neck or shoulders. My stomach quivers or feels upset. I get skin rashes or itching.

5

4

3

2

1

5

4

3

2

1

5

4

3

2

1

5

4

3

2

1

5

4

3

2

1

5

4

3

2

1

5 5

4 4

3 3

2 2

1 1 1

I have problems with my bowels (constipation, diarrhea). I need to urinate more than most people. My ulcer bothers me. I feel short of breath after mild exercise like climbing up four flights of stairs. Compared to most people, I have a very small or a very large appetite. My weight is more than 15 pounds higher than what is recommended for a person my height and build. I smoke tobacco. I get sharp chest pains when I'm physically active. I lack physical energy. When I'm resting, my heart beats more than 100 times a minute. Because of my busy schedule I miss at least two meals during the week. I don't really plan my meals for balanced nutrition. I spend less than 3 hours a week getting vigorous physical exercise (running, playing basketball, tennis, swimming, etc).

5

4

3

2

1

5 5

4 4

3 3

2 2

1 1

5

4

3

2

1

5

4

3

2

1

5 5

4 4

3 3

2 2

1 1

5 5

4 4

3 3

2 2

1 1

5

4

3

2

1

5

4

3

2

1

5

4

3

2

1

5

4

3

2

1

Physical Indicators Point total __________ 2

SLEEP INDICATORS: How often would you say: I have trouble falling asleep. I take pills to get to sleep. I have nightmares or repeated bad dreams. I wake up at least once in the middle of the night for no apparent reason. No matter how much sleep I get, I awake feeling tired.

5 5

4 4

3 3

2 2

1 1

5

4

3

2

1

5

4

3

2

1

5

4

3

2

1

Sleep Indicators Point Total __________

BEHAVIORAL INDICATORS: How often would you say: I stutter or get tongue tied when I talk to other people. I try to work while I'm eating lunch. I have to work late. I go to work even when I feel sick. I have to bring work home. I drink alcohol or use drugs to relax. I have more than two beers, eight ounces of wine or three ounces of hard liquor a day.

5

4

3

2

1

5 5

4 4

3 3

2 2

1 1

5 5

4 4

3 3

2 2

1 1

5

4

3

2

1

5

4

3

2

1

3

When I drink, I like to get really drunk. I get drunk or "high" with other drugs more than once a week. When I'm feeling high from alcohol or drugs I will drive a motor vehicle. I tend to stumble when walking, or have more accidents than other people. In any given week, I take at least one prescription drug without the recommendation of a physician, e.g. amphetamines, barbiturates. I have problems with my sex life. At least once during the week I will make bets for money. After dinner I spend more time alone or watching TV than I do talking with my family or friends. 5 I arrive at work late. At least once during the week I have a shouting match with a co-worker or supervisor....
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