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:

Total:


Section B:

Total:


Section C:

Total:


Section D:

Total:


Section E:

Total:


Total:

Total for A, B & C:

Total:

Total for C, D & E:

LIfestyle and Health Status:

times a week.
days per week.
days per week.
cigarettes daily

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