Online Survey:
 Life Style & Stress

    

Please check the answer that best describes you or your situation.

Age:

Sex:

Marital status:

Children living in your home:

(women) Are you currently pregnant?

Ethnic backgound:

Highest level of education completed:

Employment status:

Work hours:

Average hours you work each week:

Occupation:

How do you feel about your current job?

Youngest child's age in home

Do you take any herbs or vitamins designed to help your body cope better with stress emotionally or physically? (Ex. St. John's Wort, Stresstabs, Ginko)

Do you take any prescription medications for stress, depression, anxiety, panic attacks or any other mood or emotional difficulties?

Do you take any prescription medication that would be classified as an antidepressant or antianxiety for any reason other than depression, anxiety, or any mood or emotional difficulties?

Has a medical doctor, psychiatrist, psychologist, mental health counselor or social worker ever diagnosed you as having problems with anxiety, depression, anger outbursts, chemical embalance, bad nerves, alcohol or drugs, attention problems or any other problems with emotions or feelings?

Stress

Please rate on a scale from 1 to 10, how much stress you feel in the following areas of your life.
1= no stress
3= a little stress
5= a moderate amount of stress
7= a moderately high level of stress
10= an extreme amount of stress

Temporary problems and situations can effect how much stress we feel at a given time, therefore please rate how much stress you felt this past week as well as how you generally felt in these areas for the past 1 year.

   

*Note: If an area does not apply to you (EX. work items & you do not work), then just put N/A.

~~~~~~~~~~~~Level of Stress~~~~~~~~~~
Past week~~~~~~~~~~~~~~~Past year

Area of life
~~~~~~~~~

Spouse /partner

Your children

Your parents

Your siblings

Your in-laws
Friends

Peers

Supervisor

Co-workers

Work duties

Morale at work
Management at work

Physical work environment

Pay/ benefits

Customers/ clients/ patients
(people you may service at work)

Finances

Home

Automobile(s)

School/ College courses

Church/ place of worship

1=no stress
2=very little stress
3=little stress
4=little more stress
5=moderate stress
6=little more than moderate stress
7=moderately high level of stress
8=high level of stress
9=very high stress
10=extreme amount of stress

1=no stress
2=very little stress
3=little stress
4=little more stress
5=moderate stress
6=little more than moderate stress
7=moderately high level of stress
8=high level of stress
9=very high stress
10=extreme amount of stress

Childhood Experience

Please rate the following items relating to your childhood from 1 to 10.
1=very happy, pleasant experience
3=mostly happy & enjoyable
5=both happy & sad times but generally average
7=some happy times but a lot of sad times
9=mostly if not all sad times or memories
10=very sad & traumatic
0=don't remember or not applicable

Years

2-4yrs old

5 -10 yrs

11-15 yrs

15-18 yrs

Family

School

Peers

Please indicate yes if you experienced any of these events as a child or teenager. For those you experienced, please indicate your approximate age or ages (if you experienced the event at 2 or more different times (EX. loss of father age 3, then loss of stepfather age 17). If the event lasted several years then indicate time frame of ages (EX. severe illness ages 5-7). 

Death of a parent
(or parent figure)

Death of sibling
(ex. brother, sister,
cousin living in home)

Physical/ sexual abuse
(you were the victim)

Verbal abuse
(you were constantly
degraded or belittled)

Constant teasing by peers
(the kids teased & were
unusually mean to you)

Loss of home
(ex. house burned
down or destroyed)

Separated from family
(ex. you were removed
from your home &
placed in foster care)
Temporary removal
Permanent removal

Severe illness
(ex. cancer)

Injury which left
you disabled or
severely disfigured

Parent or parent figure
became disabled or severely
disfigured

Sibling or close family
member became disabled
or severely disfigured

Parents separated often
or divorced

*Identifier*
Please type in an identifying name or number which will identify both pages of your survey as belonging together. Please put the same identifyer on both pages. (EX. pet's name, child's age, initials, etc.)