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Mental Wellness
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Date *

Stress is a normal part of life. Every day, we’re faced with stimuli, called stressors, which can elicit the body’s “fight or flight” response, setting off a cascade of physiological reactions and resulting in emotions ranging from mild to intense. But while occasional stress is natural and even healthy, chronic or acute stress can be harmful.

Please take a few moments to discover your body’s response to situations you perceive as stressful. By honestly assessing how you feel, your healthcare provider can create a natural stress relief program for your individual needs.

Directions:

Please read each statement and circle the number 0, 1, 2, or 3 that best describes your feelings or reactions throughout the course of the day. Determine the subtotal score for each section, then determine the total scores for sections A-C and C-E. Some questions may appear redundant between sections. There’s a reason for each question. Don’t spend much time on any one question.

0 = Never true 1= Seldom true 2= Sometimes true 3= Often true

When under stress for two weeks or longer, I…

Section A:

1. Get wound up when I get tired and have trouble calming down

0 1 2 3

2. Feel driven, appear energetic but feel “burned out” and exhausted

0 1 2 3

3. Feel restless, agitated, anxious, and uneasy

0 1 2 3

4. Feel easily overwhelmed by emotion

0 1 2 3

5. Feel emotional — cry easily or laugh inappropriately

0 1 2 3

6. Experience heart palpitations or a pounding in my chest

0 1 2 3

7. Am short of breath

0 1 2 3

8. Am constipated

0 1 2 3

9. Feel warm, over-heated, and dry all over

0 1 2 3

10. Get mouth sores or sore tongue

0 1 2 3

11. Get hot flashes

0 1 2 3

12. Sleep less than seven hours a night

0 1 2 3

13. Have trouble falling asleep and staying asleep .

0 1 2 3

14. Worry about high blood pressure, cholesterol, and triglycerides

0 1 2 3

15. Forget to eat and feel little hunger

0 1 2 3

Total points:

Total:

Section B:

1. Find myself worrying about things big and small

0 1 2 3

2. Feel like I can’t stop worrying, even though I want to

0 1 2 3

3. Feel impulsive, pent up, and ready to explode

0 1 2 3

4. Get muscle spasms

0 1 2 3

5. Feel aggressive, unyielding, or inflexible when pressed for time

0 1 2 3

6. See, hear, and smell things that others do not

0 1 2 3

7. Stay awake replaying the events of the day or planning for tomorrow

0 1 2 3

8. Have upsetting thoughts or images enter my mind again and again

0 1 2 3

9. Have a hard time stopping myself from doing things again and again, like checking on things or rearranging objects over and over

0 1 2 3

10. Worry a lot about terrible things that could happen if I’m not careful

0 1 2 3

Total points:

Total:

Section C:

1. Have muscle and joint pains

0 1 2 3

2. Have muscle weakness

0 1 2 3

3. Crave salt or salty things

0 1 2 3

4. Have multiple points on my body that when touched are tender or painful

0 1 2 3

5. Have dark circles under my eyes

0 1 2 3

6. Feel a sudden sense of anxiety when I get hungry

0 1 2 3

7. Use medications to manage pain

0 1 2 3

8. Get dizzy when rising or standing up from a kneeling or sitting position

0 1 2 3

9. Have diarrhea or bouts of nausea with or without vomiting for no apparent reason

0 1 2 3

10. Have headaches

0 1 2 3

Total points:

Total:

Section D:

1. Have trouble organizing my thoughts

0 1 2 3

2. Get easily distracted and lose focus

0 1 2 3

3. Have difficulty making decisions and mistrust my judgment

0 1 2 3

4. Feel depressed and apathetic

0 1 2 3

5. Lack the motivation and energy to stay on task and pay attention

0 1 2 3

6. Am forgetful

0 1 2 3

7. Feel unsettled, restless, and anxious

0 1 2 3

8. Wake up tired and unrefreshed

0 1 2 3

9. Experience heartburn and indigestion

0 1 2 3

10. Catch colds or infections easily

0 1 2 3

Total points:

Total:

Section E:

1. Feel tired for no apparent reason

0 1 2 3

2. Experience lingering mild fatigue after exertion or physical activity

0 1 2 3

3. Find it difficult to concentrate and complete tasks

0 1 2 3

4. Feel depressed and apathetic

0 1 2 3

5. Feel cold or chilled – hands, feet, or all over – for no apparent reason

0 1 2 3

6. Have little or no interest in sex

0 1 2 3

7. Sweat spontaneously during the day

0 1 2 3

8. Feel puffy and retain fluids

0 1 2 3

9. Sleep more than nine hours a night

0 1 2 3

10. Have poor muscle tone

0 1 2 3

11. Have trouble losing weight

0 1 2 3

12. Wake up tired even though I seem to get plenty of sleep

0 1 2 3

13. Have no energy and feel physically weak

0 1 2 3

14. Am susceptible to colds and the flu

0 1 2 3

15. Feel dragged down by multiple symptoms, such as poor digestion and body aches

0 1 2 3

Total points:

Total:

Add points from sections A, B & C

Total:

Total for A, B & C:

Add points from sections C, D & E

Total:

Total for C, D & E:

LIfestyle and Health Status:

1. Circle the level of stress you experience on the scale of 1-10, 10 being the worst:

2. What do you consider to be the major causes of your stress (for example — spouse, family, friends, work, finances, wedding, pregnancy, legal, commute):

3. I eat breakfast

times a week.

My typical breakfast is:

4. I take a multiple vitamin/mineral

days per week.

I take a fish oil supplement

days per week.

5. I participate in 30 minutes of physical activity such as walking, aerobics (e.g., running), resistance training (e.g., weights, pilates), sports (e.g. biking), or yoga:

Daily

5-6 times per week

3-4 times per week

1-2 times per week

Less than once a week

6. I smoke

cigarettes daily

7. I drink two or more 8 ounce cups of caffeinated coffee or other caffeinated beverages like energy/diet drinks, colas, or black or green teas:

Daily

5-6 times per week

3-4 times per week

1-2 times per week

Less than once a week

8. I drink two or more ounces of alcoholic beverages:

Daily

5-6 times per week

3-4 times per week

1-2 times per week

Less than once a week

9. List your current health problems and any over-the-counter or prescription medications that you are now taking:

Current health problem(s)

Date of onset

List all current medication(s)

Our team of dedicated experienced functional medicine professionals is ready to assist you no matter where you are. We take your health seriously.

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(248) 979-7340

Back to Health Natural Solutions © 2018. All rights reserved.These statements have not been evaluated by the Food and Drug Administration. The information or care provided is not intended to diagnose, treat, cure or prevent any disease. This information provided by Back to Health Natural Solutions is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Individual results may vary.