Stress Quiz

Occupation

# Hours per week working

Age

Check any of the symptoms that you experienced in the past 30 days:*

Other symptom

Of the above, which would you like to get rid of the most?*

How long have you experienced this condition?

Number of Days, Weeks, Months or Years (according to above)

How concerned are you about this condition with 1 being not concerned and 10 being extremely concerned?

What have you tried to take care of this condition?

Has it worked?

Does this problem affect your ability to enjoy work?*

Does this problem affect your ability to enjoy family and friends?*

Does this problem affect your ability to sleep?*

On a scale of 1 - 10, how much would you like to get rid of this problem?*

Name*

First Last

Phone*

Email*