Stress Test

Your Information
Your information is collected so I can contact you about managing your stress level. I will never share your information with anyone.
Name*
First Last
Email*
Phone
Your Stress Levels
Please note: this scale is not a clinical diagnostic instrument and is provided for educational purposes. It merely identifies some of the more common symptoms of stress. If you have any concern about your state of emotional health, you can contact me, Cynthia Lackner or another health care professional.
Instructions: in the last month, how often has the following been true for you?
Select the number that fits your reality under each question
0 | Never 1 | Seldom 2 | Sometimes 3 | Often 4 | Always
1. I often feel tired.*
Please enter a number from 0 to 4.
2. My heart races and I find myself breathing rapidly.*
Please enter a number from 0 to 4.
3. I eat too much or too little.*
Please enter a number from 0 to 4.
4. I feel emotionally numb.*
Please enter a number from 0 to 4.
5. I think about my problems excessively during the day.*
Please enter a number from 0 to 4.
6. I have sleeping problems.*
(e.g. falling asleep, trouble staying asleep, trouble waking up. nightmares, etc.)
Please enter a number from 0 to 4.
7. I have trouble feeling hopeful.*
Please enter a number from 0 to 4.
8. I have back and neck pain, or other chronic tension-linked pain.*
Please enter a number from 0 to 4.
9. I have stomach upsets.*
(e.g., nausea, vomiting, diarrhea, constipation, gas)
Please enter a number from 0 to 4.
10. I have mood-swings and feel over-emotional.*
Please enter a number from 0 to 4.
11. I have trouble feeling that life is meaningful.*
Please enter a number from 0 to 4.
12. I use alcohol and/or other drugs to try and help cope.*
Please enter a number from 0 to 4.