Stress Questionnaire – Natural Health & Wellness Center

Do you frequently feel overwhelmed?*

Do you often feel "tired and wired"?*

Do you frequently feel drained?*

Do you have less energy than normal? *

Do you sometimes feel unhappy?*

Do you occasionally have trouble sleeping at night?*

Do you have difficulty in concentrating?*

Are you angered easily? *

Do you often rely on caffeine or nicotine to get through the day?*

Do you use medication (or alcohol) to cope with your stressful lifestyle? *

Name*

First Last

Phone*

Email*