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Step
1
of
12
8%
Name
First
Last
Email
On a scale of 1 to 10 (10 being severely stressed, 5 being moderately stressed, and 1 being mildly stressed), how stressed are you right now?
1
2
3
4
5
6
7
8
9
10
Look at the time, what time is it? Is the stress you are feeling right now happening between the hours of 10pm and 9am?
Yes
No
So far, have you eaten healthy today?
Yes
No
Does the stress you are feeling right now involve a close friend or family member?
Yes
No
Have you been physically active today?
Yes
No
Is the stress you are feeling right now related to school or work?
Yes
No
Did you get good, quality sleep last night?
Yes
No
Does the stress you are feeling right now involve your finances?
Yes
No
Do you have healthy supportive relationships?
Yes
No
Does the stress you are feeling right now involve any legal issue(s)?
Yes
No
Do you feel connected to those around you?
Yes
No
Do you have a sense of purpose in life?
Yes
No
Are you continuously worrying about something?
No
Yes, Mildly
Yes, Moderately
Yes, Severely
Are you feeling anxious or depressed?
No
Yes, Mildly
Yes, Moderately
Yes, Severely
Do you feel paralyzed with fear unable to do anything?
No
Yes, Mildly
Yes, Moderately
Yes, Severely
Are you feeling angry, irritable, or unable to relax?
No
Yes, Mildly
Yes, Moderately
Yes, Severely
Are you feeling overwhelmed, unmotivated, or unfocused?
No
Yes, Mildly
Yes, Moderately
Yes, Severely
Do you feel out of control or impulsive?
No
Yes, Mildly
Yes, Moderately
Yes, Severely
Are you too tired, nervous, or upset to get things done?
No
Yes, Mildly
Yes, Moderately
Yes, Severely
Do you feel detached from reality?
No
Yes, Mildly
Yes, Moderately
Yes, Severely
Are you feeling helpless and hopeless?
No
Yes, Mildly
Yes, Moderately
Yes, Severely
Do you have chest pains, a headache, or abdominal cramping?
No
Yes, Mildly
Yes, Moderately
Yes, Severely
Are you short of breath or is it hard for you to swallow?
No
Yes, Mildly
Yes, Moderately
Yes, Severely
Are you dizzy, lightheaded, or faint?
No
Yes, Mildly
Yes, Moderately
Yes, Severely
Is your heart racing or pounding?
No
Yes, Mildly
Yes, Moderately
Yes, Severely
Are you nauseous or vomiting?
No
Yes, Mildly
Yes, Moderately
Yes, Severely
Are you trembling or shaking?
No
Yes, Mildly
Yes, Moderately
Yes, Severely
Are you lacking in energy and strength?
No
Yes, Mildly
Yes, Moderately
Yes, Severely
Are you sweating?
No
Yes, Mildly
Yes, Moderately
Yes, Severely
Are your muscles tight, tense, or sore?
No
Yes, Mildly
Yes, Moderately
Yes, Severely
Are you craving a drink, a smoke, food, sweets, or other substance?
No
Yes, Mildly
Yes, Moderately
Yes, Severely
Are you making bad choices?
No
Yes, Mildly
Yes, Moderately
Yes, Severely
Δ
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2500 Castle Dr
Manhattan, NY
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