Family Service of the Piedmont

Are You Stressed Out?
Ranking Scale:
1 – Never 2 – Rarely 3 – Sometimes 4 – Frequently 5 - Always

On a scale of 1 – 5, how would you answer the following questions?

1. How frequently do you experience increased heart rate, fatigue, hyperventilation or profuse sweating?

1

2

3

4

5

2. How often do you experience an overpowering urge to cry, run or hide?

3. How often do you experience scattered thoughts, feeling disoriented or have difficulty concentrating?

4. How frequently do you feel tension, feel "on the edge", or have difficulty relaxing?

5. How often do you experience behavioral symptoms such as nail biting, teeth grinding, or use tobacco and/or alcohol to reduce your tension?

6. How frequently do you experience changes (increases or decreases) in your appetite or sleeping patterns when you feel under pressure?

7. How often do you experience neck and/or lower back pain or headaches?

8. How frequently do you complain of heartburn, ulcers, or digestive problems (irritable bowel syndrome, diarrhea, or nausea)?

9. Do you experience times where you feel unmotivated, withdraw from others, or have a decreased interest in living?

10. How often do you experience irritability, act impulsively, or describe yourself as emotionally unstable?