Health Survey

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How much are stress, anxiety and mood impacting your health?

Take this survey to find out.

1. Your Name(required)
2. Email(valid email required)
3. Phone
4. How would you describe your stress over the last six months?
5. Low
   Moderate
   High
   Very High
6. How would you describe your stress over your life??
7. Low
   Moderate
   High
   Very High

Section 1*

1. 1. Are you troubled by excessive worrying at least 50% of the time, difficulty controlling your worrying, OR persistent worrying for at least 6 months?
2. Yes
   No
3. 2. Have you been bothered by any of the following for at least 6 months?
4. Restlessness, feeling keyed-up or on edge
   Being easily tired
   Problems concentrating
   Irritability
   Muscle tension
   Trouble falling asleep or staying asleep, or restless and unsatisfying sleep
   Anxiety interfering with your daily life
   

Section 2**

1. Which best describes you
2. 1. Falling asleep:
3. I never take longer than 30 mnutes to fall asleep.
   I take at least 30 minutes to fall asleep, less than half the time.
   I take at least 30 minutes to fall asleep, more than half the time.
   I take more than 60 minutes to fall asleep, more than half the time.
4. 2. Sleep during the night:
5. I do not wake up at night.
   I have a restless, light sleep with a few brief awakenings each night.
   I wake up at least once a night, but I go back to sleep easily.
   I awaken more than once a night and stay awake for 20 minutes or more, more than half the time.
6. 3. Waking up to early:
7. Most of the time, I awaken no more than 30 minutes before I need to get up.
   More than half the time, I awaken more than 30 minutes before I need to get up.
   I almost always awaken at least one hour or so before i need to, but go back to sleep eventually.
   I awaken at least one hour before I need to, and can't go back to sleep.
8. 4. Sleeping too much:
9. I sleep no longer than 7-8 hours/night, without napping during the day.
   I sleep no longer than 10 hours in a 24-hour period, including naps.
   I sleep no longer than 12 hours in a 24-hour period including naps.
   I sleep longer than 12 hours in a 24-hour period including naps.
10. Appetite/Weight Section
11. 5. Decreased appetite (in past 1 year):
12. There is no decrease in my usual appetite.
    I eat somewhat less often or lesser amounts of food than usual.
    I eat much less than usual and only with personal effort.
    I rarely eat within a 24-hour period, and only with extreme personal effort when others persuade me to eat.
13. 6. Increased appetite (in the past 1 year):
14. There is no increase in my usual appetite.
    I feel a need to eat more frequently than usual.
    I regularly eat more often and/or greater amounts of food than usual.
    I feel driven to overeat both at mealtime and between meals.
15. 7. Decreased weight (within the last 6 months):
16. I have not had a change in my weight.
    I feel as if I've had a slight weight loss.
    I have lost 2 pounds or more.
    I have lost 5 pounds or more.
17. 8. Increased weight (within the last 6 months):
18. I have not had a change in my weight.
    I feel as if I have had a slight weight gain.
    I have gained 2 pounds or more.
    I have gained 5 pounds or more.
19. Psychomotor Section
20. 9. Feeling slowed down:
21. I think, speak, and move at my usual rate of speed.
    I find that my thinking has slowed down or my voice sounds dull or flat.
    It takes me several seconds to respond to most questions and I'm sure my thinking is slowed.
    I am often unable to respond to questions without extreme effort.
22. 10. Feeling restless:
23. I do not feel restless.
    I'm often fidgety, wringing my hands, or need to shift how I'm sitting.
    I have impulses to move about and am quite restless.
    At times, I am unable to stay seated and need to pace around.
24. Individual Questions
25. 11. Feeling sad:
26. I do not feel sad.
    I feel sad less than half the time.
    I feel sad more than half the time.
    I feel sad nearly all of the time.
27. 12. Concentration/Decision making:
28. There is no change in my usual capacity to concentrate or make decisions.
    I occasionally feel indecisive or find that my attention wanders.
    Most of the time, I struggle to focus my attention or to make decisions.
    I cannot concentrate well enough to read or cannot make even minor decisions.
29. 13. View of myself:
30. I see myself as equally worthwhile and deserving as other people.
    I am more self-blaming than usual.
    I largely believe that I cause problems for others.
    I think almost constantly about major and minor defects in myself.
31. 14. Thoughts of death or suicide:
32. I do not think about suicide or death.
    I feel that life is empty or wonder if it's worth living.
    I think of suicide or death several times a week for several minutes.
    I think of suicide or death several times a day in some detail, or I have made specific plans for suicide or have acutally tried to take my life.
33. 15. General interest:
34. There is no change from usual how interested I am in other people or activities.
    I notice that I am less interested in people or activities.
    I find I have interest in only one or two of my formerly pursued activities.
    I have virtually no interest in formerly pursued activities.
35. 16. Energy level:
36. There is no change in my usual level of energy.
    I get tired more easily than usual.
    I have to make a big effort to start or finish my usual daily activities (for example, shopping, homework, cooking or going to work).
    I really cannot carry out most of my usual daily activities because I just don't have the energy.

Section 3***

1. 1. I feel tired or have a lack of energy.
2. Never
   Rarely
   Sometimes
   Fairly often
   Always
3. 2. I have trouble sitting still or concentrating.
4. Never
   Rarely
   Sometimes
   Fairly often
   Always
5. 3. I have problems getting to or staying asleep at night.
6. Never
   Rarely
   Sometimes
   Fairly often
   Always
7. 4. I feel pain in my chest and shortness of breath.
8. Never
   Rarely
   Sometimes
   Fairly often
   Always
9. 5. I am constipated or have diarrhea.
10. Never
    Rarely
    Sometimes
    Fairly often
    Always
11. 6. I feel nervous, and shake or sweat a lot.
12. Never
    Rarely
    Sometimes
    Fairly often
    Always
13. 7. I have an upset stomach and muscle aches, especially in my back, neck, or shoulders.
14. Never
    Rarely
    Sometimes
    Fairly often
    Always
15. 8. I have headaches.
16. Never
    Rarely
    Sometimes
    Fairly often
    Always
17. 9. I smoke and/or drink alcohol.
18. Never
    Rarely
    Sometimes
    Fairly often
    Always
19. 10. I have gained or lost more than 10 pounds.
20. Never
    Rarely
    Sometimes
    Fairly often
    Always

 

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*Taken from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition.
**Adapted from the Quick Inventory of Depressive Symptamatology Self-Report developed by A. John Rush MD
*** Developed from questionnaire by Jerome F. Kiffer, MA, Department of Health Psychology and Applied Psychophysiology, The Cleveland Clinic Foundation.

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