Stress Indicator
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,
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,