Stress Questionnaire

This questionnaire is intended to be a subjective assessment of stressors and related symptoms and complaints.

To obtain score, multiply points, by Duration.

Part 1
Adrenal Related Problems Section	Points Per Section	Duration Years			Score
Excessive Fatigue	10	1/2	1	2	____
Dry & Thin skin	10	1/2	1	2	____
Nervousness / Irritability	9	1/2	1	2	____
Low body temperature	8	1/2	1	2	____
Premenstrual tension	8	1/2	1	2	____
Inability to concentrate	8	1/2	1	2	____
Mental depression	8	1/2	1	2	____
Food allergies & sensitivities	8	1/2	1	2	____
Craving for sweets	7	1/2	1	2	____
Headaches	6	1/2	1	2	____
Alcohol intolerance	6	1/2	1	2	____
Poor memory	5	1/2	1	2	____
Heart palpitation	5	1/2	1	2	____
Total:					____
Do you have chronic pain: Yes No

Scoring:
30 or less	Minimal probability of Adrenal Axis-Stress related problem.
31 - 50	Moderate probability of Adrenal Axis-Stress related problem.
51 and above	High probability of Adrenal Axis-Stress related problem

Social Readjustment Rating Scale

Part 2
Circle yes or no to each life event in this list that happened in the last twelve months. Upon completion, total each point value to achieve the total score.
Life Event	Answer		Point Value	Score Value
Death of spouse	Yes	No	100	____
Divorce	Yes	No	73	____
Marital separation	Yes	No	65	____
Jail term	Yes	No	63	____
Death of close family member	Yes	No	63	____
Personal injury or illness	Yes	No	53	____
Marriage	Yes	No	50	____
Fired from work	Yes	No	47	____
Marital reconciliation	Yes	No	45	____
Retirement	Yes	No	45	____
Change in family member's health	Yes	No	44	____
Pregnancy	Yes	No	40	____
Sex difficulties	Yes	No	39	____
Addition to family	Yes	No	39	____
Business readjustment	Yes	No	39	____
Change in financial status	Yes	No	38	____
Death of a close friend	Yes	No	37	____
Change in line of work	Yes	No	36	____
Change in number of marital arguments	Yes	No	35	____
Mortgage or loan over $10,000	Yes	No	31	____
Foreclosure of mortgage or loan	Yes	No	30	____
Change in work responsibilities	Yes	No	29	____
Son or daughter leaving home	Yes	No	29	____
Trouble with in-laws	Yes	No	29	____
Outstanding personal achievement	Yes	No	28	____
Spouse begins or stops work	Yes	No	26	____
Starting or finishing school	Yes	No	26	____
Change in living conditions	Yes	No	25	____
Revision of personal habits	Yes	No	24	____
Trouble with boss	Yes	No	23	____
Change in work hours, conditions	Yes	No	20	____
Change in residence	Yes	No	20	____
Change in schools	Yes	No	20	____
Change in recreational habits	Yes	No	19	____
Change in church activities	Yes	No	18	____
Mortgage or loan under $10,000	Yes	No	18	____
Change in sleeping habits	Yes	No	16	____
Change in number of family gatherings	Yes	No	15	____
Change in eating habits	Yes	No	15	____
Vacation	Yes	No	13	____
Christmas season	Yes	No	12	____
Minor violation of the law	Yes	No	11	____
Score Total				____

150 or less	37% chance of getting sick within the next two years. Roughly one in three.
151 -1299	50%Chance of illness within the next two years
300 or above	80% chance of illness within the next two years

*Copyright Holmes, TH and Rahe, RH Booklet for Schedule of Recent Experience (SRE), Seattle, University of Washington, 1967