Stress Response System Questionnaire

This questionnaire will help your doctor learn more about how well your body is responding to stress. Consider each question carefully, then click the "Yes" or "No" button to indicate how well the question describes you. Your total score will be tallied at the bottom of the questionnaire once all the questions are answered.

 

 
1 pt for each yes
Yes
No
Do you frequently have low body temperatures? (<98 degrees F)
Do you frequently get irritable?
Do you have poor memory or concentration?
Do you notice palpitations?
Do you suffer from allergies or asthma?
Do you bruise easily or find your wounds heal slowly?
Do you get frequent/chronic infections?
Do you have dry, thinning skin?
Do you get headaches?
Do you have unexplained hair loss?
Do you skip meals?
Do you exercise less than twice each week?
Do you have thyroid problems?
Do you lack energy during the day?
Do you need caffeine in the morning or after lunch?
 
3 points for each yes
Yes
No
Are you emotionally overstressed?
Do you get tenderness across your lower back?
Do you suffer from depression or down moods?
Do you have low blood pressure?
Do you experience a "second wind" (high energy) at bedtime?
Do you experience chronic or recurrent inflammation?
Do you get light headed when sitting up or standing?
 
5 points for each yes
Yes
No
Do you suffer from chronic pain?
Do you suffer from low blood sugar/hypoglycemia?
(i.e. headaches, sleepiness, mood swings if skipping meals)
Do you suffer from insomnia?
Do you experience symptoms of PMS?
(breast tenderness, abdominal cramping, heavy periods, mood swings)
Are you menopausal or peri menopausal?
(skipped periods, between 45-55 yrs old, hot flashes, vaginal dryness)
 
Total: