Please download and fill in the stress assessment questionnaire

Stress Management Training S1.c

Session One

Stress Assessment Questionnaire

Name………………………………………………………………………………………………………………………….

How would you describe the problem?

 

How long have you had the problem?

 

How did the problem first start?

 

What does your Doctor say about the problem?

 

Have you had any treatment in the past?

 

Have you tried to overcome the problem in the past?

 

Have you had any success in overcoming the problem?

 

Do you suffer from any of the following?:

Headaches

Blushing

Dizziness

Heartburn

Weak knees

Chest pains

Itching

Blurred vision

Light-headedness

Missed heartbeat

Sleep disturbance

Breathlessness 

Difficulty swallowing

Anxiety 

Facial tics

Nausea

Frightening thoughts

Worrying

Loneliness

Disorganisation

Poor memory 

Diarrhoea

Allergies

Tiredness

Faintness

Nightmares

Palpitations

Rash

Uncontrollable eye movement

Unreal feelings 

Muscular tension

Excessive sweating

Sexual difficulties 

‘Lump in the throat’

Panic attacks 

Sensitivity to light and sound

Shaking

Hating yourself 

Talking too fast 

Boredom 

Poor concentration

Irritability

Do you fear any of the following?:

Future events

Collapsing

Panic attacks

Losing control 

Crowded places

Driving

Being on a train

Supermarkets

Talking to people 

People looking at you

Bridges

Being alone

Social occasions 

Waiting rooms

Dogs 

Choking

Fainting

Being embarrassed

Madness

Standing in queues

Being on a bus

Being in shops

Leaving the house

Eating in front of people 

Writing in front of people

Tunnels

Going to work

Cinemas, theatres

Medical examinations

Birds

 Do you suffer from unpleasant thoughts that you feel are beyond your control?

 

Do you feel compelled to do certain actions to control these thoughts?

 

Do you work outside the home?

 

Do you live alone or with family or friends?

 

Have your parents or brothers/sisters ever suffered from any psychological problems?

 

What are your hobbies/Social life?

 

Do you smoke? (and how many a day, for how many years, and in what circumstances)?

 

Do you drink alcohol? (and how much a week, for how many years and in what circumstances)?

 

Are you taking any medication?

 

How is your physical health?

 

What are your most serious symptoms? How do they affect your life at the present time?

 

Optional : Return your completed form to your coach for review: Email: [email protected]