mood-and-stress-questionnaire - Client Form Mood and Stress Questionnaire - Client Form PART 1: PATIENT TO FILL OUTName (optional) EmailDatePreviousNextValue Equivalent: 0 = Less than 1 day per week; 1 = 1 or 2 days per week; 2 = 3 or 4 days per week; 3 = 5 or more days per week Please choose one option only for the most accurate result.Section 1: Please review the list below and tick the answer that best represents how you felt over the last week. Feel ‘wired but tired’ – anxious but lethargic. less than 1 day per week 1-2 days per week 3-4 days per week 5+ days per week I feel restless and exhausted when stressed. less than 1 day per week 1-2 days per week 3-4 days per week 5+ days per weekI feel tired all day but then cannot sleep at night or wake early in the morning and cannot get back to sleep. less than 1 day per week 1-2 days per week 3-4 days per week 5+ days per weekI get easily overstimulated by even mild amounts of caffeine or sugar. less than 1 day per week 1-2 days per week 3-4 days per week 5+ days per weekSection 1 - Total PreviousNextSection 2: Please review the list below and tick the answer that best represents how you felt over the last week. Please choose one option only for the most accurate result. Feel like my ‘battery is flat’. less than 1 day per week 1-2 days per week 3-4 days per week 5+ days per weekI feel mentally and physically exhausted. less than 1 day per week 1-2 days per week 3-4 days per week 5+ days per weekI find it hard to get motivated to start or complete tasks. less than 1 day per week 1-2 days per week 3-4 days per week 5+ days per weekI find it hard to get going in the mornings. less than 1 day per week 1-2 days per week 3-4 days per week 5+ days per weekSection 2 - Total PreviousNextSection 3: Please review the list below and tick the answer that best represents how you felt over the last week. Please choose one option only for the most accurate result. Feel downhearted and sad. less than 1 day per week 1-2 days per week 3-4 days per week 5+ days per weekI find it hard to get enthusiastic about anything. less than 1 day per week 1-2 days per week 3-4 days per week 5+ days per weekI find it difficult to work up the initiative to do things. less than 1 day per week 1-2 days per week 3-4 days per week 5+ days per weekI see nothing in my future to be hopeful about. less than 1 day per week 1-2 days per week 3-4 days per week 5+ days per weekSection 3 - Total Save ProgressPreviousNextSection 4: Please review the list below and tick the answer that best represents how you felt over the last week. Please choose one option only for the most accurate result.I feel anxious and worried. less than 1 day per week 1-2 days per week 3-4 days per week 5+ days per weekI feel panicky or distressed. less than 1 day per week 1-2 days per week 3-4 days per week 5+ days per weekI find it difficult to relax. less than 1 day per week 1-2 days per week 3-4 days per week 5+ days per weekI feel nervous and tense. less than 1 day per week 1-2 days per week 3-4 days per week 5+ days per weekSection 4 - Total PreviousNextSection 5: Please review the list below and tick the answer that best represents how you felt over the last week. Please choose one option only for the most accurate result.I get easily irritated, frustrated, grumpy or moody. less than 1 day per week 1-2 days per week 3-4 days per week 5+ days per weekIt takes me a long time to wind down if something upsets me. less than 1 day per week 1-2 days per week 3-4 days per week 5+ days per weekI suffer from shoulder and/or neck pain and/or stiffness. less than 1 day per week 1-2 days per week 3-4 days per week 5+ days per weekI find myself getting impatient when I am delayed in any way (e.g. traffic lights, lifts, being kept waiting). less than 1 day per week 1-2 days per week 3-4 days per week 5+ days per weekSection 5 - Total PreviousNextSection 6: Please review the list below and tick the answer that best represents how you felt over the last week. Please choose one option only for the most accurate result.I worry excessively. less than 1 day per week 1-2 days per week 3-4 days per week 5+ days per weekI feel teary or cry easily when stressed. less than 1 day per week 1-2 days per week 3-4 days per week 5+ days per weekI find it difficult making decisions and/or tend to brood on things from the past. less than 1 day per week 1-2 days per week 3-4 days per week 5+ days per weekI feel overwhelmed, like everything is too much to cope with. less than 1 day per week 1-2 days per week 3-4 days per week 5+ days per weekSection 6 - Total PreviousNextSection 7: Please review the list below and tick the answer that best represents how you felt over the last week. Please choose one option only for the most accurate result.I find it difficult to fall asleep and/or stay asleep. less than 1 day per week 1-2 days per week 3-4 days per week 5+ days per weekI wake unrefreshed. less than 1 day per week 1-2 days per week 3-4 days per week 5+ days per weekI find it difficult to relax or ‘switch off ’, especially at night. less than 1 day per week 1-2 days per week 3-4 days per week 5+ days per weekI feel intense anxiety or panic. less than 1 day per week 1-2 days per week 3-4 days per week 5+ days per weekSection 7 - Total Previous Submit Form
