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Stress Balance Assessment

Select one of the five responses for each of the fourteen questions.

0 = Not present, 1 = Mild, 2 = Moderate, 3 = Severe, 4 = Very severe.

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Your initials please^*

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Thank you, ___. Would you be willing to share your email with us?^*

Just to send your results. We'll never spam your inbox!!

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What is your age?^*

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Gender^*

Male

Female

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Education^*

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Marital Status^*

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Anxious mood^*

Worries, anticipation of the worst, fearful anticipation, irritability

0 → Not present

4 → Very severe

Not present Very severe

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Tension^*

Feelings of tension, fatigability, startle response, moved to tears easily, trembling, feelings of restlessness, inability to relax

0 → Not present

4 → Very severe

Not present Very severe

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Fears^*

Of dark, of strangers, of being left alone, of animals, of traffic, of crowds

0 → Not present

4 → Very severe

Not present Very severe

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Insomnia^*

Difficulty in falling asleep, broken sleep, unsatisfying sleep and fatigue on waking, dreams, nightmares, night terrors

0 → Not present

4 → Very severe

Not present Very severe

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Intellectual^*

Difficulty in concentration, poor memory

0 → Not present

4 → Very severe

Not present Very severe

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Depressed mood^*

Loss of interest, lack of pleasure in hobbies, depression, early waking, diurnal swing

0 → Not present

4 → Very severe

Not present Very severe

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Somatic (muscular)^*

Pains and aches, twitching, stiffness, myoclonic jerks, grinding of teeth, unsteady voice, increased muscular tone

0 → Not present

4 → Very severe

Not present Very severe

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Somatic (sensory)^*

Tinnitus, blurring of vision, hot and cold flushes, feelings of weakness, pricking sensation

0 → Not present

4 → Very severe

Not present Very severe

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Cardiovascular symptoms^*

Tachycardia, palpitations, pain in chest, throbbing of vessels, fainting feelings, missing beat

0 → Not present

4 → Very severe

Not present Very severe

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Respiratory symptoms^*

Pressure or constriction in chest, choking feelings, sighing, dyspnea

0 → Not present

4 → Very severe

Not present Very severe

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Gastrointestinal symptoms^*

Difficulty in swallowing, wind abdominal pain, burning sensations, abdominal fullness, nausea, vomiting, borborygmi, looseness of bowels, loss of weight, constipation

0 → Not present

4 → Very severe

Not present Very severe

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Genitourinary symptoms^*

Frequency of micturition, urgency of micturition, amenorrhea, menorrhagia, development of frigidity, premature ejaculation, loss of libido, impotence

0 → Not present

4 → Very severe

Not present Very severe

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Autonomic symptoms^*

Dry mouth, flushing, pallor, tendency to sweat, giddiness, tension headache, raising of hair

0 → Not present

4 → Very severe

Not present Very severe

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Autonomic symptoms^*

Fidgeting, restlessness or pacing, tremor of hands, furrowed brow, strained face, sighing or rapid respiration, facial pallor, swallowing, etc

0 → Not present

4 → Very severe

Not present Very severe

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How do you feel after answering this questionnaire^*

1 → Unsatisfied

10 → Satisfied

Unsatisfied Satisfied

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We are eager to hear more about how we can better support the community. Share what we're missing...

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Book a session with us and jump right in with your first one completely free.

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Welcome back! Loading your previous answers...

Stress Balance Assessment

Anxious mood *

Tension *

Fears *

Insomnia *

Intellectual *

Depressed mood *

Somatic (muscular) *

Somatic (sensory) *

Cardiovascular symptoms *

Respiratory symptoms *

Gastrointestinal symptoms *

Genitourinary symptoms *

Autonomic symptoms *

Autonomic symptoms *

How do you feel after answering this questionnaire *

Thank you

Anxious mood^*

Tension^*

Fears^*

Insomnia^*

Intellectual^*

Depressed mood^*

Somatic (muscular)^*

Somatic (sensory)^*

Cardiovascular symptoms^*

Respiratory symptoms^*

Gastrointestinal symptoms^*

Genitourinary symptoms^*

Autonomic symptoms^*

Autonomic symptoms^*

How do you feel after answering this questionnaire^*