Name

Age

How often do you feel overwhelmed? Never Rarely Sometimes Often Always

How often do you have trouble sleeping due to stress? Never Rarely Sometimes Often Always

How often do you feel irritable or anxious? Never Rarely Sometimes Often Always

How often do you experience physical symptoms like headaches or muscle tension? Never Rarely Sometimes Often Always

Describe a recent stressful event.

On a scale of 1-10, how would you rate your overall stress level?

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