Stress Questionnaire

Stress Questionnaire

Stress may be related to many other secondary health concerns. Proper assessment and a treatment plan are important to optimize one’s health.

This subjective questionnaire will give your health care practitioner a quick summary of symptoms or signs that may be related to your degree of stress and adrenal gland. It is not a substitute for professional medical advice from your health care provider.

For each “Yes” answer, circle the Point Score in that section. Score the following with the numbers in brackets choosing the severity that best suits you when indicated.
Add your points at the end and enter in the total score.

1.   ____ Do you feel overwhelmed? ( 100)
2.   ____Do you have difficulties falling asleep , staying asleep or waking early in the morning unable to return to sleep? (100)
3.   ____ Do you crave sugar or salt or caffeine? ( 100)
4.   ____ Do you have blood sugar concerns ie diabetes or hypoglycemia ( feeling unwell after sweets or long periods between meals ) ? ( 100)
5.   ____ Do you carry extra weight around the abdominal area? ( 70)
6.   ____ Do you exercise less than:
• 3 times per week for 30 minutes each time? ( 50)
• 2 times per week for 30 minutes each time? ( 70)
• Once per week for 30 minutes? ( 90)
• I do not exercise? ( 100)
7.   ____ Rank your degree of stress, on a scale of 1/10 , 10 with the greatest amount :
• 1-4 ( 30)
• 5-6 ( 50)
• 7-8 ( 70)
• 9-10 ( 100)
8.   ____ I am able to share how I feel ( easily 10, moderately 30, not able to 50)
9.   ____I have difficulties focusing and remembering ? ( 80)
10. ____ I often feel tired or “ wired” (100)

Total Score______

If you have a total score of more than 300 there is a probability that you are at risk for stress related disease.  It is recommended to have the stress panel tests to assess your proper treatment plan.

Book An Appointment