Stress Response

Name of the patient *

Name of the referring Doctor

Contact Number of Individual / Referring Doctor *

Email Address

Date of Birth of Patient *

Gender & Marital Status *

1. When tasks and duties build up to the extent that they are hard to manage *I am generally untroubledI usually feel a little uneasyI normally get quite nervous

2. When I want to relax after a hard day at work . . . *This is usually quite difficult for meI usually succeedI generally have no problem at all

3. When I have conflicts with others that may not be immediately resolved . . . *I generally shrug it offIt usually affects me a littleIt usually affects me a lot

4. When I make a mistake . . . *In general, I remain confidentI sometimes feel unsure about my abilitiesoften have doubts about my abilities

5. When I’m wrongly criticized by others . . . *I am normally annoyed for a long timeI am annoyed for just a short timeIn general, I am hardly annoyed at all

6. When I argue with other people . . . *I usually calm down quicklyI usually stay upset for some timeIt usually takes me a long time until I calm down

7. When I have little time for a job to be done . . . *I usually stay calmI usually feel uneasyI usually get quite agitated

8. When I make a mistake . . . *I am normally annoyed for a long timeI am normally annoyed for a whileI generally get over it easily

9. When I am unsure what to do or say in a social situation . . . *I generally stay coolI often feel warmI often begin to sweat

10. When I have spare time after working hard . . . *It often is difficult for me to unwind and relaxI usually need some time to unwind properlyI am usually able to unwind effectively and forget about the problems of the day

11. When I am criticized by others . . . *Important arguments usually come to my mind when it is too late to still make my pointI often have difficulty finding a good replyI usually think of a reply to defend myself

12. When something does not go the way I expected . . . *I usually stay calmI often get uneasyI usually get very agitated

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