PROCARE — Confidential Stress Assessment Form

Confidential Stress
Assessment

**RECOGNIZE SIGNS OF STRESS**

Confidential Stress Assessment Form

Date: Organisation: Branch/area: Organisation Position:

To assess the extent to which stress is affecting your health, think back over the last month. Read each statement below and decide, question by question, which score best describes your present physical and emotional state.

I get sudden feelings of fear and panic: I feel tense, nervous, or wound up: I am troubled by difficulty in going to sleep, staying asleep, or early wakening: I worry something awful might happen: I feel irritable, on edge, and bad-tempered: I have irregular eating patterns and either eat too much or too little: I smoke or drink too much, or take tranquillizers or other drugs: I get headaches or migraines: I have difficulty with concentration, memory, or making decisions: I feel exhausted and tired: I feel apathetic – nothing matters: I feel short of breath even when resting: I get tightness in my chest, neck or head: I avoid worrying situations: I feel dizzy, remote, unreal, or faint: I cannot “turn off” certain worrying thoughts: I have lost interest in sexual activity: I get palpitations or a sensation of butterflies in my stomach or chest: I lack confidence in myself: I worry that I will not be able to cope: I suffer from an upset stomach, diarrhoea, or constipation: I feel life is not worth living: I worry that I will lose control, “crack up”, or become ill: I feel pessimistic about the future: I feel under strain: I get aches and pains that worry me: I feel very emotional and cry easily: I feel physically run down: I put off seeing friends and have no interest in hobbies: