Stress Test Daily Stress Checklist How are your mind and body affected by the common sources of stress? Please take your time to consider each item on this checklist, and mark those items that you currently experience. Relationship Stress I am grieving from the death of a friend I experience everyday stress because of my relationship with an immediate family member I have recently experienced a loss of friendship I feel excluded by my family I am grieving from the death of a child I am grieving from a death of a family member (not spouse or child) I experience everyday stress because of my relationship with a member of my extended family Caregiver Stress I am the primary caregiver in my family with one or more children I am responsible for caring for an aging family member or members I am the caregiver of child, sibling, or parent with special needs Social Stress I feel stressed by the number of social committments I have I often feel lonely, alone, or isolated Financial Stress I am in conflict with my spouse or family over our financial decisions I am in a conflict with a co-worker/business partner over finances I am responsible for the primary income for my family I can honestly say I live above my means, and I do not know what to do about it I am anxious about my financial situation Physical Stress I have recently been in a car accident (including "minor" fender benders) I need to replace my mattress My sleep quality is poor because I cannot fall asleep or stay asleep I engage in long distance endurance running, swimming, biking, etc. I regularly aid in lifting and transporting an aged family member or relative I am carrying more weight than I want My footwear is not supportive for the demands I place on my feet I do not have a regular exercise program I have recently fallen or stumbled or slipped I am still experiencing symptoms from a neck injury/whiplash My work station ergonomics are poor My walk/run unevenly wears the soles of my shoes I am still experiencing symptoms from a mild traumatic brain injury I do not have a regular stretch or movement routine I have chronic foot, ankle, knee, or hip degeneration or injury that changes the way I walk or run I regularly lift and transport young children My work or hobbies require a lot of repetitive motion I use electronic devices for more than an hour per day I engage in physical exercise and wonder if I am using the proper form I am recovering from a surgery or surgeries Chemical Stress I have tested positive for a gene mutation that reduces my natural detoxification ability I rely on over the counter pain relievers I have hobbies that increase my exposure to chemicals I have seasonal allergies I am addicted to caffeine I do not currently use air filtration or air purification in my home I am addicted to nicotine I am exposed to industrial stength chemicals in my home I drink more than I probably should I regularly use recreational drugs I live near a high traffic area (freeway or main thoroughfare) I am currently withdrawing from caffeine I do not currently use water purification in my home I have food allergies I eat more sugar than I probably should I am currently overcoming an addiction to recreational drugs I am currently withdrawing from nicotine I am on two or more regular medications I know I have nutritional deficiencies I am exposed to industrial strength chemicals in my workplace Career Stress My work environment is physically or emotionally draining I am in conflict with my boss I am in conflict with my co-workers I am asked to cover shortcoming of other workers, or short-staffing situations I am not adequately paid for my position My work is not very satisfying I do not get enough vacation time There is little opportunity for advancement in my current position I feel like I could be fired at any minute I spend too much time at work Life Transition Stress I am in the process of purchasing or selling a home I am moving/recently moved away from family and close friends I am moving or expanding a business I am having a baby I am getting married I am getting divorced I am grieving the death of my spouse Email* Enter Email Confirm Email Please enter your email to receive a copy of your information, and your score. Keep in mind that most email is not HIPAA safe. All information provided via this web form is confidential, and your email will not be shared or sold or distributed in any way. Name* First NameThis field is for validation purposes and should be left unchanged.