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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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Anxious mood *
Worries, anticipation of the worst, fearful anticipation, irritability
0 → Not present
4 → Very severe
Tension *
Feelings of tension, fatigability, startle response, moved to tears easily, trembling, feelings of restlessness, inability to relax
0 → Not present
4 → Very severe
Fears *
Of dark, of strangers, of being left alone, of animals, of traffic, of crowds
0 → Not present
4 → Very severe
Insomnia *
Difficulty in falling asleep, broken sleep, unsatisfying sleep and fatigue on waking, dreams, nightmares, night terrors
0 → Not present
4 → Very severe
Intellectual *
Difficulty in concentration, poor memory
0 → Not present
4 → Very severe
Depressed mood *
Loss of interest, lack of pleasure in hobbies, depression, early waking, diurnal swing
0 → Not present
4 → Very severe
Somatic (muscular) *
Pains and aches, twitching, stiffness, myoclonic jerks, grinding of teeth, unsteady voice, increased muscular tone
0 → Not present
4 → Very severe
Somatic (sensory) *
Tinnitus, blurring of vision, hot and cold flushes, feelings of weakness, pricking sensation
0 → Not present
4 → Very severe
Cardiovascular symptoms *
Tachycardia, palpitations, pain in chest, throbbing of vessels, fainting feelings, missing beat
0 → Not present
4 → Very severe
Respiratory symptoms *
Pressure or constriction in chest, choking feelings, sighing, dyspnea
0 → Not present
4 → Very severe
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
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
Autonomic symptoms *
Dry mouth, flushing, pallor, tendency to sweat, giddiness, tension headache, raising of hair
0 → Not present
4 → Very severe
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
How do you feel after answering this questionnaire *
1 → Unsatisfied
10 → Satisfied
/
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