Indicate the word that describes the degree to which
each statement is true.
I have a supportive family.
Never
Seldom
Sometimes
Often
Always
I have a network of friends and acquaintances.
Never
Seldom
Sometimes
Often
Always
I have one or more friends with whom I can share personal
matters.
Never
Seldom
Sometimes
Often
Always
I give and receive affection regularly.
Never
Seldom
Sometimes
Often
Always
I am able to speak openly about my feelings when angry or
worried.
Never
Seldom
Sometimes
Often
Always
I take time to discuss domestic problems such as chores, money,
daily-living issues.
Never
Seldom
Sometimes
Often
Always
I belong to social activity group that meets regularly (other
than my family).
Never
Seldom
Sometimes
Often
Always
I get strength from my spiritual beliefs.
Never
Seldom
Sometimes
Often
Always
I have adequate income to meet my basic expenses.
Never
Seldom
Sometimes
Often
Always
I practice time management techniques.
Never
Seldom
Sometimes
Often
Always
I actively pursue a hobby.
Never
Seldom
Sometimes
Often
Always
I do something I really enjoy which is `just for me’ during the
course of an average week.
Never
Seldom
Sometimes
Often
Always
There is a place in my environment where I can go to relax and/or
be by myself.
Never
Seldom
Sometimes
Often
Always
I am in good health (including eyesight, hearing, teeth)
Never
Seldom
Sometimes
Often
Always
I choose foods that are low in fat, sugar, and salt.
Never
Seldom
Sometimes
Often
Always
I use medication or chemical substances (including alcohol) to
help me sleep.
Never
Seldom
Sometimes
Often
Always
I use medication or chemical substances (including alcohol) to
reduce my anxiety or just calm me down.
Never
Seldom
Sometimes
Often
Always
I practice some form of `deep relaxation', such as yoga,
meditation, imagery, autogenics, progressive, etc.
Never
Once a week
Two times a week
Three times a week
Over three times a week
I exercise to the point of perspiration.
Never
Once a week
Two times a week
Three times a week
Over three times a week
In a typical week, the number of nights I get sufficient sleep to
wake up refreshed is.
One or two
Three
Four
Five
Six or seven
Considering my height, bone structure, and muscle mass, my body
weight is this many pounds above or below my recommended weight.
+/- 21 pounds
+/- 16-21 pounds
+/- 11-15 pounds
+/- 6-10 pounds
+/- 5 pounds
With regard to cigarettes, I smoke.
20+ per day
11-19 per day
Under 10 per day
Only when drinking alcohol
None
With regard to other forms of tobacco consumption my daily use of
noncigarette tobacco (cigars, pipe, chewing tobacco, snuff).
20 or more per day
11-19 per day
10 or less per day
Only when drinking alcohol
None
My alcohol consumption in drinks per week (1 drink = 1 beer, 1
glass of wine, 1 mixed drink).
10 or more
6 to 10
3 to 5
1 to 2
0
My daily consumption of caffeine beverages (coffee, tea, cola).
5 or more
3 to 4
2 to 3
0 to 1
More Information
If you would like to learn some additional stress balancing
skills, check which areas below you would be interested in learning
about.
