Mood and Stress Questionnaire - Naturopath Solutions

Full Name

Date

E-mail address

VALUE EQUIVALENT 0 = Less than 1 day per week; 1 or 2= 1 or 2 days per week; 2 or 4= 3 or 4 days per week; 3 or 6 = 5 or more days per week

Please review the list below and tick the answer that best represents how you felt over the last week.

SECTION 1: I feel ‘wired but tired’ – anxious but lethargic.

0

2

4

6

I feel restless and exhausted when stressed.

0

2

4

6

I feel tired all day but then cannot sleep at night or wake early in the morning and cannot get back to sleep.

0

1

2

3

I get easily overstimulated by even mild amounts of caffeine or sugar.

0

1

2

3

SECTION 1 Total

SECTION 2:I feel like my ‘battery is flat’.

0

2

4

6

I feel mentally and physically exhausted.

0

2

4

6

I find it hard to get motivated to start or complete tasks.

0

1

2

3

I find it hard to get going in the mornings.

0

1

2

3

SECTION 2 Total

SECTION 3: I feel downhearted and sad.

0

2

4

6

I find it hard to get enthusiastic about anything.

0

2

4

6

I find it difficult to work up the initiative to do things.

0

1

2

3

I see nothing in my future to be hopeful about.

0

1

2

3

SECTION 3 Total

SECTION 4: I feel anxious and worried.

0

2

4

6

I feel panicky or distressed.

0

2

4

6

I find it difficult to relax.

0

1

2

3

I feel nervous and tense.

0

1

2

3

SECTION 4 Total

SECTION 5: I get easily irritated, frustrated, grumpy or moody.

0

2

4

6

It takes me a long time to wind down if something upsets me.

0

2

4

6

I suffer from shoulder and/or neck pain and/or stiffness.

0

1

2

3

I find myself getting impatient when I am delayed in any way (e.g. traffic lights, lifts, being kept waiting).

0

1

2

3

SECTION 5 Total

SECTION 6: I worry excessively.

0

2

4

6

I feel teary or cry easily when stressed.

0

2

4

6

I find it difficult making decisions and/or tend to brood on things from the past.

0

1

2

3

I feel overwhelmed, like everything is too much to cope with.

0

1

2

3

SECTION 6 Total

SECTION 7: I find it difficult to fall asleep and/or stay asleep.

0

2

4

6

I wake unrefreshed.

0

2

4

6

I find it difficult to relax or ‘switch off ’, especially at night.

0

1

2

3

I feel intense anxiety or panic.

0

1

2

3

SECTION 7 Total