Please print out this section and fill it out on paper.  You can also choose select all under edit, copy it, paste it into an email, answer the questions and email them to me. Answer your questions in all capital letters or highlight your answer some way.

Stress and Relaxation

1.  Do you often feel overstressed? Y  N

2.  If yes, on average how many days per week? ____

3.  Does stress sometimes interfere with your health, personal satisfaction, or ability to be productive at work?  Y   N

4.  Is your job often stressful?  Y  N

5.  If yes, in what way?

6.  Rank the stress you experience in a typical day on a scale of 1-5, 5 being extremely stressed and 1 not being stressed.

7.  Do you get 7-8 hours of sleep on a  regular basis?  Y  N

8.  Would you consider the sleep you get quality sleep? Y  N

9.  Are you sometimes unable to relax when you want to?  Y  N

10.  What are some ways that you relax/de-stress?  _____________________________________________

11.  Have you ever tried exercising as a de-stressor?  Y  N

12.  If yes, what did you do and was it effective?

13.  List some factors that stimulate stress for you.

  

*Check one of the choices to answer questions 14 - 16.

14.     When you are stressed do you typically:

         __overeat  __undereat  __eat the same?

15. When you are stressed do you typically:

      __over exercise  __under exercise __exercise the same?

16.  When you are stressed do you typically:

        __gain weight  __lose weight  __maintain the same weight?

17.  Please list any specific goals related to stress management:

Look at the 43 entries of the Social Readjustment Rating Scale below.  Each entry has a number for its relative stress value.  Choose those that apply to you in the last 12 months and add up your stress value numbers.  At the end is an explanation of your score.

__1. Death of a spouse  100

__2.  Divorce     73

__3.  Marital Separation 65

__4  Jail Term  63    

__5. Death of a close Family member  63

__6. Personal illness or injury  53

__7.  Marriage  50

__8.  Fired at work  47

__9.  Marital Reconciliation  45

__10.  Retirement  45

__11. Change in Health of Family Member  44

__12.  Pregnancy   40

__13.  Sex Difficulties  39

__14.  Gain new family member  39

__15.  Business Readjustment   39

__16.  Change in financial state   38

__17.  Death of a close friend        37

__18.  Change to different line of work  36

__19.  Change in number of arguments with spouse  35

__20.  Mortgage over $10,000  31

__21.  Foreclosure of mortgage or loan  30

__22.  Change in responsibilities at work  29

__23.  Son or daughter leaving home  29

__24.  Trouble with in-laws  29

__25.  Outstanding personal achievement  28

__26.  Secondary wage earner - begins or stops work  26

__27.  Begin or End School  26

__28.  Change in living conditions  25

__29.  Revision of personal habits  24

__30.  Trouble with boss  23

__31.    Change in work hours or conditions  21

__32.  Change in residence  20

__33.  Change in schools  20

__34.  Change in recreation  19

__35.  Change in chruch activities  19

__36.  Change in social activities  18

__37.  Mortgage or loan less than $10,000     17

__38.  Change in sleeping habits  16

__39.  Change in number of family get-togethers  15

__40.  Change in eating habits  15

__41.  Vacation  13

__42.  Christmas  12

__43.  Minor violations of the law  11

Score 300 or more indicates an extreme amount of energy being used for social readjustment behaviors:  score of 299-150 indicates and excessive amount of energy is being used for social readjustment behaviors.  Score of 150-11 indicates a moderate amount of energy is being used for social readjustment behaviors.

Read more about this rating scale and the relationship of stress to your health here, here and here.

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