| Behavior statement | Daily frequency rating | ||
| Usually (2 points) | Sometimes (1 point) | Infrequently (0 points) | |
| I am not able to find the time to relax. | __ | __ | __ |
| When I do find the time, it is difficult to relax. | __ | __ | __ |
| I have difficulty maintaining my concentration because of worrying or negative thoughts. | __ | __ | __ |
| At the end of the workday I have difficulty turning work off enough to start the next day energized. | __ | __ | __ |
| I have tension, headaches, sleep disturbances, neck or shoulder pain, or lower back pain. | __ | __ | __ |
| I feel muscle tension or have a nervous stomach or irritable bowel. | __ | __ | __ |
| I use food, alcohol, or tobacco in response to distress. | __ | __ | __ |
| I take any kind of drug to relax. | __ | __ | __ |
| People in my immediate life, home, or workplace cause me to feel distressed. | __ | __ | __ |
| I feel anxiety or a general emotional heaviness. | __ | __ | __ |
| 0 to 5 | You very rarely experience unhealthy stress and are at low risk. |
| 6 to 12 | You are at medium risk for experiencing unhealthy stress and may want to mae a few changes in your daily habits |
| 13 to 20 | You are at high risk for compromising your health because of daily stresses and you should seriously consider making some changes in your daily habits. |
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