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STRESSOR QUESTIONNAIRE
Instructions: In the space behind each identified stressor, describe your particular stressor, and on the scale below
that item, mark the severity of that stressor on the scale provided.
The lowest possible score is zero and the highest is 84. Once you reach 42 and above, your stress levels may begin to
affect your health.
1. EMOTIONAL STRESSORS (specific fears, phobias, worries, feelings of low self-worth, depression, etc.)______
___________________________________________________________________________________
0 1 2 3 4 5 6 7
2. FAMILY STRESSORS (spouse, children, in-laws, etc.)________________________________________
_________________________________________________
0 1 2 3 4 5 6 7
3. SOCIAL STRESSORS (someone difficult for you to get along with, someone’s expectations of you, feelings of
social inadequacy, etc.)____________________________________________________________________
_________________________________________________
0 1 2 3 4 5 6 7
4. FINANCIAL STRESSORS (money problems that are out of your control)___________________________
___________________________________________________________________________________
_________________________________________________
0 1 2 3 4 5 6 7
5. CHANGE STRESSORS (leaving a job, house, or relationship; new situations or people in your life, etc.)_______
_________________________________________________
0 1 2 3 4 5 6 7
6. CHEMICAL STRESSORS (medications with side-effects, alcohol, caffeine, nicotine, etc.)________________
_________________________________________________
0 1 2 3 4 5 6 7
7. WORK & COMMUTING STRESSORS (the particular demands of homework [i.e. disciplining children, cleaning, etc.], relationships
with co-workers, job insecurity, unemployment, getting to work, commuting children, etc.) _________________________________________________
0 1 2 3 4 5 6 7
8. DECISION STRESSORS (responsibility to make right decisions with many alternatives and time pressures)____
_________________________________________________
0 1 2 3 4 5 6 7
9. PHYSICAL STRESSORS (fatigue, not enough sleep, poor nutrition, an injury, pregnancy)________________
_________________________________________________
0 1 2 3 4 5 6 7
10. DISEASE & PAIN STRESSORS (headaches, arthritis, allergies, ulcers, cancer, coronary problems, etc.)____
_________________________________________________
0 1 2 3 4 5 6 7
11. OTHER (please include stressors not included above and rate them)_________________________________
_________________________________________________
0 1 2 3 4 5 6 7
12. OTHER _________________________________________________
0 1 2 3 4 5 6 7
© Trauma Awareness & Treatment Center—Permission required by Larry Beall, Ph.D. to copy or reproduce
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