StressQuest - StressQuest

StressQuest Self Assessment

Are you ready to focus? This questionnaire will take about 15 minutes to complete, but it will be worth your time!

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Please complete all required fields!

Who referred you to our 'StressQuest'?*

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Please take note of the fact that your personal information will be treated confidentially.

Do you mind sharing basic information about yourself?*

Yes No Invalid Input

Full Name*

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Email Address*

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Contact Number*

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Your Age*

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Your Gender*

Female
Male
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Country of Birth*

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Country and City/Town of Residence?

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For how long have you been living in this country?*

Less than 4 years
4-6 years
7-9 years
More than 9 years Invalid Input

Your Conjugal Status*

Married
Divorced
De Facto Relationship
Widow(er)
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Your Occupation*

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Your Religious Affiliation*

Christian
Jew
Hindu
Buddhist
Muslim
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Please note that this questionnaire consists of a number of statements, and uses a value scale of 1-5.
Number 1 on this value scale represents total disagreement with the statement, and number 5 represents total agreement with the statement.

Do you understand that you are required to attach those values to the statements in this questionnaire that represent how you feel or what you believe to be true?*

Yes Invalid Input

When considering statements 1.1 - 1.14, think in terms of any one or more of the following groups you are involved with. Tick the appropriate box / boxes.

Family
Friends
Work
Club
Church
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1.1 I OFTEN FEEL irritated, due to sensory discomfort caused by hunger / tiredness / pain / cold / warmth / noise / bad odours / distasteful visual sites.*

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5 Invalid Input

1.2 I OFTEN FEEL overwhelmed and unable to deal successfully with whatever is demanded of me, and I believe that I'm overloaded and under resourced.*

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5 Invalid Input

1.3 I OFTEN FEEL deprived, and believe that I do not get opportunities to participate, to make my contributions, to give what I've got, and to realise my dreams.*

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5 Invalid Input

1.4 I OFTEN FEEL financially under resourced, and believe that I will not be able to meet my financial responsibilities.*

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5 Invalid Input

1.5 I OFTEN FEEL frustrated and believe that I'm unsuccessful and failing to reach my goals.*

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1.6 I OFTEN FEEL guilty and disappointed and believe that I do not live according to my own rules.*

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1.7 I OFTEN FEEL ashamed and believe that I do not meet the standards set by my parents / spouse / loved ones / friends / co-workers / team mates.*

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5 Invalid Input

1.8 I OFTEN FEEL disregarded and believe that my parents / spouse / loved ones / friends / co-workers / team mates do not recognise, validate and respect me.*

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5 Invalid Input

1.9 I OFTEN FEEL controlled and disempowered, and believe that I am not free to be myself, to make my own choices and to carry out my own decisions.*

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5 Invalid Input

1.10 I OFTEN FEEL betrayed due to disloyalty shown by my parents / loved ones / friends / co-workers / team mates.*

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5 Invalid Input

1.11 I OFTEN FEEL sad, after losing someone or something recently that means a lot to me.*

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5 Invalid Input

1.12 I OFTEN FEEL confused, experiencing an inconsistent situation, within which I am not certain what to expect and what is expected of me, not understanding my role and what the agreed rules and boundaries are.*

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5 Invalid Input

1.13 I OFTEN FEEL lonely and socially disconnected - longing for a sense of togetherness within a network of meaningful, reciprocal, caring relationships.*

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5 Invalid Input

1.14 I OFTEN FEEL unhealthy and believe that I may have developed a serious health problem.*

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5 Invalid Input

1.15 I OFTEN FEEL hopeless and believe my life lost its meaning.*

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5 Invalid Input

1.16 I OFTEN FEEL threatened, unsafe, agitated or even angry, and believe that things are not the way it should be.*

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5 Invalid Input

2.1 I OFTEN EXPERIENCE EPISODES during which my sensory organs detect unusual odours, sounds, images or flavours in my immediate environment that make me feel quite alert for a while. *

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2.2 I OFTEN EXPERIENCE EPISODES during which my body undergoes 1 or more of the following sudden changes: my heartbeat suddenly speeds up; my heart rhythms suddenly become unusual; my face suddenly turns pale (according to others).*

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2.3 I OFTEN EXPERIENCE EPISODES during which my body undergoes 1 or more of the following sudden changes: blood pressure suddenly rises; hands or fingers suddenly start shaking; jaw / neck / shoulder / lower back muscles become tensed.*

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5 Invalid Input

2.4 I OFTEN EXPERIENCE EPISODES during which my body undergoes 1 or more of the following sudden changes: body / hands start sweating; difficulty emptying bowel or bladder.*

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5 Invalid Input

2.5 I OFTEN EXPERIENCE EPISODES during which my body undergoes 1 or more of the following sudden changes: breathing suddenly speeds up; become light-headed; mouth suddenly becomes dry.*

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5 Invalid Input

2.6 I OFTEN EXPERIENCE EPISODES during which my body undergoes 1 or more of the following sudden changes: mind suddenly becomes more alert; develop more visual sensitivity; develop indigestion, diarrhoea or constipation. *

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5 Invalid Input

2.7 I OFTEN EXPERIENCE EPISODES during which my energy levels suddenly rise.*

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5 Invalid Input

3.1 LATELY, I EXPERIENCE 1 or more of the following: an underlying sense of anger / danger; a tendency to display aggressive behaviour.*

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5 Invalid Input

3.2 LATELY, I EXPERIENCE 1 or more of the following: having trouble falling asleep; having trouble obtaining a restful nights sleep; inability to control my weight.*

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3.3 LATELY, I EXPERIENCE 1 or more of the following: a tendency to become ill more often; less resistance to infections; a tumour; tissue containing a growth.*

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3.4 LATELY, I EXPERIENCE 1 or more of the following: a tendency to distance myself from friends / family / responsibilities; a lack of job satisfaction / motivation.*

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3.5 LATELY, I EXPERIENCE 1 or more of the following: resentfulness; a cynical attitude; an I don't care attitude; a feeling of being overwhelmed by life; mood swings.*

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3.6 LATELY, I HAVE NOTICED 1 or more of the following: a slow but steady rise in my regular blood pressure; persistent high blood pressure; regular heart burn.*

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3.7 LATELY, I HAVE NOTICED 1 or more of the following: period of heightened energy levels turned into period of fatigue, lack of energy, tiredness in morning; lateness for work; procrastination; needed 3-day weekends; turning work in late.*

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3.8 LATELY, I HAVE NOTICED 1 or more of the following: decreased sexual desire; masculine traits appeared (in women); boldness appeared (by men).*

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5 Invalid Input

3.9 LATELY, I HAVE NOTICED 1 or more of the following: forgetfulness; inability to concentrate; muscular wasting.*

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5 Invalid Input

3.10 LATELY, I TEND TO EXPERIENCE the following: general feelings of discomfort, aches and pains. *

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3.11 LATELY, I TEND TO EXPERIENCE 1 or more of the following: tensed muscles; posture problems; backache; tightness in my throat / chest cavity; lock-jaw; muscle tears / pulls; eye problems.*

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5 Invalid Input

3.12 LATELY, I TEND TO EXPERIENCE 1 or more of the following: periods of headache / migraine; grinding teeth at night; increase in water retention (swollen hands / feet). *

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3.13 LATELY, I TEND TO EXPERIENCE 1 or more of the following: ulcer; periods of diarrhoea / constipation; lower-bowel spasms; upper abdominal cramps; irritable bowel; absence of menstruation (women).*

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4.1 I AM STRUGGLING WITH / have been diagnosed with 1 or more of the following: permanent high blood pressure (hypertension); bronchial asthma; overactive thyroid (hyperthyroidism).*

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4.2 I AM STRUGGLING WITH / have been diagnosed with 1 or more of the following: hardening of arteries (atherosclerosis); diabetes 2; obesity; heart disease; increased loss of bone mass and strength (osteoporosis).*

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4.3 I AM STRUGGLING WITH / have been diagnosed with 1 or more of the following: general sexual dysfunction; erectile dysfunction (impotence); chronic fatigue; memory loss; alzheimer's disease.*

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4.4 I AM STRUGGLING WITH / have been diagnosed with 1 or more of the following: inflammatory, chronically relapsing eczema (atopic dermatitis); dark red raised itchy bumps (urticaria).*

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4.5 I AM STRUGGLING WITH / have been diagnosed with 1 or more of the following: recurring episodes of non-inflammatory swelling of skin (angioneurotic edema); discoloration of fingers, toes, brittle nails with longitudinal ridges (raynaud's disease).*

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4.6 I AM STRUGGLING WITH / have been diagnosed with 1 or more of the following: chronic sadness; major depression; anger management problems.*

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5.1 I TEND TO engage in high risk / physical demanding activities which temporarily make me feel better / help relief my aches and pains / give me energy, eg. extreme sport, gambling, watching pornography.*

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5.2 I TEND TO frequently use or sometimes binge on substances containing large amounts of refined sugar, artificial sweeteners, carbohydrates, caffeine, nicotine, alcohol, stimulants, tranquilisers, etc.*

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5 Invalid Input

5.3 I TEND TO eat certain foods that cause me to breathe with difficulty / give me a stuffy nose / diarrhoea / red itchy bumps on my skin.*

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5 Invalid Input

5.4 I TEND TO increase the quantity of the above mentioned activities / substances / foods that I engage in, use or binge on, over time.*

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5.5 I TEND NOT TO adhere to a definite set sleep and wake up time.*

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5 Invalid Input

5.6 I TEND NOT TO eat 4-6 small healthy meals per day.*

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5.7 I TEND NOT TO walk / exercise for 20-30 minutes daily.*

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5.8 I TEND NOT TO relax my body and rest my mind for a couple of seconds, after stressful moments during the average day.*

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5.9 I TEND NOT TO wear clothing aimed at protecting by body and sensory organs against hyper / hypothermia, dehydration, UV radiation, poison, dangerous objects or noise, typically associated with my life / work / recreational context.*

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5.10 I TEND NOT TO intentionally focus on keeping my body and my gastro-intestinal tract clean, keeping the good bacteria within my gastro-intestinal tract alive and healthy.*

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5.11 I TEND NOT TO adhere to a "six-day-work / one-day-no-work" week, where "work" refers to what I do for a living, as well as maintaining, managing and administering my private business and tasks in and around my home.*

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5.12 I TEND NOT TO engage in daily "only-us moments" (intentionally planned, quality time) with loved ones living at home.*

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