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Stress Management Questionnaire

Fill out the form below and click "Submit"
to send us your information for evaluation.

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Name*:

Email*:

Do you frequently feel overwhelmed?*:

Yes No

Do you often feel tried and wired?*:

Yes No

Do you frequently feel drained?*:

Yes No

Do you have less energy than normal?*:

Yes No

Do you sometimes feel unhappy?*:

Yes No

Do you occasionally have trouble sleeping at night?*:

Yes No

Do you have difficulty in concentrating?*:

Yes No

Do you often relay on caffeine or nicotine to get through the day?*:

Yes No

Are you angered easily?*:

Yes No

Do you use medication (or alcohol) to cope with your stressful lifestyle?*:

Yes No

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