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Stress Indicators Questionnaire

This document contains a stress indicators questionnaire to assess how stress affects different areas of a person's life. It includes sections on physical indicators, sleep indicators, and behavioral indicators. For each indicator, respondents are asked to rate how often they experience each symptom or behavior on a scale from 1-5, with 5 being "almost always" and 1 being "never". The total scores in each section can indicate the level of stress being experienced physically, with sleep, and through behaviors.

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M7md Allahham
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289 views2 pages

Stress Indicators Questionnaire

This document contains a stress indicators questionnaire to assess how stress affects different areas of a person's life. It includes sections on physical indicators, sleep indicators, and behavioral indicators. For each indicator, respondents are asked to rate how often they experience each symptom or behavior on a scale from 1-5, with 5 being "almost always" and 1 being "never". The total scores in each section can indicate the level of stress being experienced physically, with sleep, and through behaviors.

Uploaded by

M7md Allahham
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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

PERSONAL PROFILE

1. Gender a) Male b)Female

2. Age a) [16, 18) b) [18, 20) c) [20, 22)

3. Educational qualification

4. Martial status a)Married b)Unmarried

E
5. Salary

6. Experience

7. Present position

PHYSICAL INDICATORS: How often would you say:

Almost Most of Some of Almost


s.no Particulars Never
Always the time the time never
1 My body feels tense all over. 5 4 3 2 1
2 I have a nervous sweat or sweaty palms. 5 4 3 2 1
3 I have a hard time feeling really relaxed. 5 4 3 2 1
4 I have severe or chronic lower back pain. 5 4 3 2 1
5 I get severe or chronic headaches. 5 4 3 2 1
6 I get tension or muscle spasms in my face, jaw,
5 4 3 2 1
neck or shoulders.
7 My stomach quivers or feels upset. 5 4 3 2 1
8 I get skin rashes or itching. 5 4 3 2 1
9 I have problems with my bowels 5 4 3 2 1
(constipation, diarrhea).
10 I need to urinate more than most people. 5 4 3 2 1
11 My ulcer bothers me. 5 4 3 2 1
I

1
12 I feel short of breath after mild exercise like 5 4 3 2 1
climbing up four flights of stairs.
13 Compared to most people, I have a very small 5 4 3 2 1
or a very large appetite.
14 My weight is more than 15 pounds
recommended for a person my height and 5 4 3 2 1
build.
15 I smoke tobacco. 5 4 3 2 1
16 I get sharp chest pains when I'm physically 5 4 3 2 1
active.
17 I lack physical energy. 5 4 3 2 1
18 When I'm resting, my heart beats more than 5 4 3 2 1
100 times a minute.
19 Because of my busy schedule I miss at least 5 4 3 2 1
two meals during the week.
20 I don't really plan my meals for balanced 5 4 3 2 1
nutrition.
21 I spend less than 3 hours a week getting
vigorous physical exercise (running, playing 5 4 3 2 1
basketball, tennis, swimming, etc).

Physical Indicators Point total __________


SLEEP INDICATORS: How often would you say:

s.no Almost Most of Some of Almost


Particulars Never
Always the time the time never
1 I have trouble falling asleep. 5 4 3 2 1
2 I take pills to get to sleep. 5 4 3 2 1
3 I have nightmares or repeated bad dreams. 5 4 3 2 1
4 I wake up at least once in the middle of the
5 4 3 2 1
night for no apparent reason.
5 No matter how much sleep I get, I awake
5 4 3 2 1
feeling tired.

Sleep Indicators Point Total __________

BEHAVIORAL INDICATORS: How often would you say:

s.no Almost Most of Some of Almost


Particulars Never
Always the time the time never
1 I stutter or get tongue tied when I talk to
5 4 3 2 1
other people.
2 I try to work while I'm eating lunch. 5 4 3 2 1
3 I have to work late. 5 4 3 2 1
4 I go to work even when I feel sick. 5 4 3 2 1
5 I have to bring work home. 5 4 3 2 1
6 I drink alcohol or use drugs to relax. 5 4 3 2 1

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