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Sample Assessment

Have you felt stressed in the last 30 days as the result of...

1. ...a loss due to the death of a loved one?
2. ...a loss due a break up with a loved one or a child moving out of the house?
3. ...you or a loved one having trouble with the law?
4. ...conflict with someone?
5. ...being physically, sexually, or emotionally abused?
6. ...you abusing someone physically, sexually, or emotionally?
7. ...you or a loved one suffering from an addiction?
8. ...taking on more than you can handle, over scheduling yourself, or having difficulty managing all of your responsiblities?
9. ...setting unrealistic goals OR your lack of desire to set and/or reach your goals?
10. ...a new home, new job, new baby, new school, new relationship, new project?
11. ...you or a loved one's physical health due to an illness, injury, disease, poor diet, lack of exercise, or significant weight change?
12. ...you or your loved one's financial health due to reduced income and/or increased debt/expense?
13. ...your job/career loss, displeasure, responsiblities, deadlines, or satisfaction?
14. ...your sexual health due to performance issues, attaction issues, or sexual orientation struggles?
15. ...supportive relationship, severed friendships, or decreased family time?
16. ...a struggle with your religious beliefs or meaning of life?
17. ...experiencing/witnessing a traumatic event, living with someone that is very negative/mentally ill, or being lonely?

When you have felt stressed in the last 30 days, do you...

18. ...experience physical symptoms such as muscle tension, stiffness, shortness of breath, dizziness, inability to relax, headaches, worn out, or sleep problems?
19. ...feel angry, anxious, confused, worried, numb, irritated, overwhelmed, depressed, or fearful?

Have you experienced or been diagnosed with any of the following...

20. ...cancer, chronic pain, depression, anxiety, gastrointestinal problems, headaches, heart disease, or obesity?

1. Have you felt stressed in the last 30 days as the result of a loss due to the death of a loved one?

Frequency: How often do you feel stress from this?

1. ...Occasionally
2. ...Often
3. ...Constantly

Severity: How significant of a stress is this for you?

4. ...Mild
5. ...Moderate
6. ...Severe

Duration: How long have I been stressed by this?

7. ...Short period of time? (Less than a month)
8. ...Medium period of time? (Less than a year)
9. ...Long period of time? (Greater than a year)

2. Have you felt stressed in the last 30 days as the result of a loss due a break up with a loved one or a child moving out of the house?

Frequency: How often do you feel stress from this?

10. ...Occasionally
11. ...Often
12. ...Constantly

Severity: How significant of a stress is this for you?

13. ...Mild
14. ...Moderate
15. ...Severe

Duration: How long have I been stressed by this?

16. ...Short period of time? (Less than a month)
17. ...Medium period of time? (Less than a year)
18. ...Long period of time? (Greater than a year)

3. Have you felt stressed in the last 30 days as the result of you or a loved one having trouble with the law?

Frequency: How often do you feel stress from this?

19. ...Occasionally
20. ...Often
21. ...Constantly

Severity: How significant of a stress is this for you?

22. ...Mild
23. ...Moderate
24. ...Severe

Duration: How long have I been stressed by this?

25. ...Short period of time? (Less than a month)
26. ...Medium period of time? (Less than a year)
27. ...Long period of time? (Greater than a year)

4. Have you felt stressed in the last 30 days as the result of conflict with someone?

Frequency: How often do you feel stress from this?

28. ...Occasionally
29. ...Often
30. ...Constantly

Severity: How significant of a stress is this for you?

31. ...Mild
32. ...Moderate
33. ...Severe

Duration: How long have I been stressed by this?

34. ...Short period of time? (Less than a month)
35. ...Medium period of time? (Less than a year)
36. ...Long period of time? (Greater than a year)

5. Have you felt stressed in the last 30 days as the result of being physically, sexually, or emotionally abused?

Frequency: How often do you feel stress from this?

37. ...Occasionally
38. ...Often
39. ...Constantly

Severity: How significant of a stress is this for you?

40. ...Mild
41. ...Moderate
42. ...Severe

Duration: How long have I been stressed by this?

43. ...Short period of time? (Less than a month)
44. ...Medium period of time? (Less than a year)
45. ...Long period of time? (Greater than a year)

6. Have you felt stressed in the last 30 days as the result of you abusing someone physically, sexually, or emotionally?

Frequency: How often do you feel stress from this?

46. ...Occasionally
47. ...Often
48. ...Constantly

Severity: How significant of a stress is this for you?

49. ...Mild
50. ...Moderate
51. ...Severe

Duration: How long have I been stressed by this?

52. ...Short period of time? (Less than a month)
53. ...Medium period of time? (Less than a year)
54. ...Long period of time? (Greater than a year)

7. Have you felt stressed in the last 30 days as the result of you or a loved one suffering from an addiction?

Frequency: How often do you feel stress from this?

55. ...Occasionally
56. ...Often
57. ...Constantly

Severity: How significant of a stress is this for you?

58. ...Mild
59. ...Moderate
60. ...Severe

Duration: How long have I been stressed by this?

61. ...Short period of time? (Less than a month)
62. ...Medium period of time? (Less than a year)
63. ...Long period of time? (Greater than a year)

8. Have you felt stressed in the last 30 days as the result of taking on more than you can handle, over scheduling yourself, or having difficulty managing all of your responsiblities?

Frequency: How often do you feel stress from this?

64. ...Occasionally
65. ...Often
66. ...Constantly

Severity: How significant of a stress is this for you?

67. ...Mild
68. ...Moderate
69. ...Severe

Duration: How long have I been stressed by this?

70. ...Short period of time? (Less than a month)
71. ...Medium period of time? (Less than a year)
72. ...Long period of time? (Greater than a year)

9. Have you felt stressed in the last 30 days as the result of setting unrealistic goals OR your lack of desire to set and/or reach your goals?

Frequency: How often do you feel stress from this?

73. ...Occasionally
74. ...Often
75. ...Constantly

Severity: How significant of a stress is this for you?

76. ...Mild
77. ...Moderate
78. ...Severe

Duration: How long have I been stressed by this?

79. ...Short period of time? (Less than a month)
80. ...Medium period of time? (Less than a year)
81. ...Long period of time? (Greater than a year)

10. Have you felt stressed in the last 30 days as the result of a new home, new job, new baby, new school, new relationship, new project?

Frequency: How often do you feel stress from this?

82. ...Occasionally
83. ...Often
84. ...Constantly

Severity: How significant of a stress is this for you?

85. ...Mild
86. ...Moderate
87. ...Severe

Duration: How long have I been stressed by this?

88. ...Short period of time? (Less than a month)
89. ...Medium period of time? (Less than a year)
90. ...Long period of time? (Greater than a year)

11. Have you felt stressed in the last 30 days as the result of you or a loved one's physical health due to an illness, injury, disease, poor diet, lack of exercise, or significant weight change?

Frequency: How often do you feel stress from this?

91. ...Occasionally
92. ...Often
93. ...Constantly

Severity: How significant of a stress is this for you?

94. ...Mild
95. ...Moderate
96. ...Severe

Duration: How long have I been stressed by this?

97. ...Short period of time? (Less than a month)
98. ...Medium period of time? (Less than a year)
99. ...Long period of time? (Greater than a year)

12. Have you felt stressed in the last 30 days as the result of you or your loved one's financial health due to reduced income and/or increased debt/expense?

Frequency: How often do you feel stress from this?

100. ...Occasionally
101. ...Often
102. ...Constantly

Severity: How significant of a stress is this for you?

103. ...Mild
104. ...Moderate
105. ...Severe

Duration: How long have I been stressed by this?

106. ...Short period of time? (Less than a month)
107. ...Medium period of time? (Less than a year)
108. ...Long period of time? (Greater than a year)

13. Have you felt stressed in the last 30 days as the result of your job/career loss, displeasure, responsiblities, deadlines, or satisfaction?

Frequency: How often do you feel stress from this?

109. ...Occasionally
110. ...Often
111. ...Constantly

Severity: How significant of a stress is this for you?

112. ...Mild
113. ...Moderate
114. ...Severe

Duration: How long have I been stressed by this?

115. ...Short period of time? (Less than a month)
116. ...Medium period of time? (Less than a year)
117. ...Long period of time? (Greater than a year)

14. Have you felt stressed in the last 30 days as the result of your sexual health due to performance issues, attaction issues, or sexual orientation struggles?

Frequency: How often do you feel stress from this?

118. ...Occasionally
119. ...Often
120. ...Constantly

Severity: How significant of a stress is this for you?

121. ...Mild
122. ...Moderate
123. ...Severe

Duration: How long have I been stressed by this?

124. ...Short period of time? (Less than a month)
125. ...Medium period of time? (Less than a year)
126. ...Long period of time? (Greater than a year)

15. Have you felt stressed in the last 30 days as the result of supportive relationship, severed friendships, or decreased family time?

Frequency: How often do you feel stress from this?

127. ...Occasionally
128. ...Often
129. ...Constantly

Severity: How significant of a stress is this for you?

130. ...Mild
131. ...Moderate
132. ...Severe

Duration: How long have I been stressed by this?

133. ...Short period of time? (Less than a month)
134. ...Medium period of time? (Less than a year)
135. ...Long period of time? (Greater than a year)

16. Have you felt stressed in the last 30 days as the result of a struggle with your religious beliefs or meaning of life?

Frequency: How often do you feel stress from this?

136. ...Occasionally
137. ...Often
138. ...Constantly

Severity: How significant of a stress is this for you?

139. ...Mild
140. ...Moderate
141. ...Severe

Duration: How long have I been stressed by this?

142. ...Short period of time? (Less than a month)
143. ...Medium period of time? (Less than a year)
144. ...Long period of time? (Greater than a year)

17. Have you felt stressed in the last 30 days as the result of experiencing/witnessing a traumatic event, living with someone that is very negative/mentally ill, or being lonely?

Frequency: How often do you feel stress from this?

145. ...Occasionally
146. ...Often
147. ...Constantly

Severity: How significant of a stress is this for you?

148. ...Mild
149. ...Moderate
150. ...Severe

Duration: How long have I been stressed by this?

151. ...Short period of time? (Less than a month)
152. ...Medium period of time? (Less than a year)
153. ...Long period of time? (Greater than a year)

18. When you have felt stressed in the last 30 days, do you experience physical symptoms such as muscle tension, stiffness, shortness of breath, dizziness, inability to relax, headaches, worn out, or sleep problems?

Frequency: How often do you feel stress from this?

154. ...Occasionally
155. ...Often
156. ...Constantly

Severity: How significant of a stress is this for you?

157. ...Mild
158. ...Moderate
159. ...Severe

Duration: How long have I been stressed by this?

160. ...Short period of time? (Less than a month)
161. ...Medium period of time? (Less than a year)
162. ...Long period of time? (Greater than a year)

19. When you have felt stressed in the last 30 days, do you feel angry, anxious, confused, worried, numb, irritated, overwhelmed, depressed, or fearful?

Frequency: How often do you feel stress from this?

163. ...Occasionally
164. ...Often
165. ...Constantly

Severity: How significant of a stress is this for you?

166. ...Mild
167. ...Moderate
168. ...Severe

Duration: How long have I been stressed by this?

169. ...Short period of time? (Less than a month)
170. ...Medium period of time? (Less than a year)
171. ...Long period of time? (Greater than a year)

20. Have you experienced or been diagnosed with any of the following cancer, chronic pain, depression, anxiety, gastrointestinal problems, headaches, heart disease, or obesity?

Frequency: How often do you feel stress from this?

172. ...Occasionally
173. ...Often
174. ...Constantly

Severity: How significant of a stress is this for you?

175. ...Mild
176. ...Moderate
177. ...Severe

Duration: How long have I been stressed by this?

178. ...Short period of time? (Less than a month)
179. ...Medium period of time? (Less than a year)
180. ...Long period of time? (Greater than a year)