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STRESS SYMPTOMS CHECKLIST
Name_________________________
Indicate the degree each of the following symptoms have occurred in your life the past month, using the following scale:
0 = Not at All 1 = a Little 2 = Moderately 3 = Quite a Bit 4 = Extremely
Score Symptoms
PHYSICAL
1. _______ Headaches
2. _______ Fatigue, tiredness
3. _______ Sore or tense muscles
4. _______ Stomach distress
5. _______ Rapid heart beat
6. _______ Cold hands and feet
7. _______ Increased sweating
8. _______ Nervousness, restlessness
9. _______ Body aches and pain
10. ______ Diarrhea or constipation
11. ______ Rashes, acne, allergies
EMOTIONAL
12. ______ Anger, resentment
13. ______ Despair, depression
14. ______ Feeling scared, fearful
15. ______ Irritability
16. ______ Feeling tense and keyed up
17. ______ Frustration
18. ______ Panicky feelings
19. ______ Shaking, trembling
20. ______ Feeling overwhelmed, helplessness
21. ______ Hopelessness about the future
22. ______ Feeling trapped
Score Symptoms MENTAL
23. ______ Trouble concentrating
24. ______ Racing thoughts
25. ______ Difficulty making decisions
26. ______ Trouble remembering things
27. ______ Confusion of thought
28. ______ Dwelling in stressful problems
29. ______ Negative thoughts about self
30. ______ Wandering thoughts, daydreaming
BEHAVIORAL
31. ______ Wasting time
32. ______ Withdrawal, increased quietness
33. ______ Jumping from one activity to another
34. ______ Impatience, temper outbursts
35. ______ Crying
36. ______ Increased or decreased eating
37. ______ Increased or decreased sleeping
38. ______ Escaping, running away for awhile
39. ______ Doing insignificant things, avoiding important tasks
______ TOTAL
Indicate on the following scale the overall degree of stress you have felt the past month.
No stress Extreme stress
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0 1 2 3 4 5 6 7 8 9 10
© Trauma Awareness & Treatment Center—Permission required by Larry Beall, Ph.D. to copy or reproduce
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