Become an Ona Insider

Contact Us

To Get 10% off Your First Visit!

    Stress is a normal part of life. Every day, we’re faced with stimuli, called stressors, which can elicit the body’s “fight or flight” response, setting off a cascade of physiological reactions and resulting in emotions ranging from mild to intense. But while occasional stress is natural and even healthy, chronic or acute stress can be harmful.

    Please take a few moments to discover your body’s response to situations you perceive as stressful. By honestly assessing how you feel, your healthcare provider can create a stress relief program for your individual needs.

    Please read each statement and circle the number 0, 1, 2, or 3 that best describes your feelings or reactions throughout the course of the day. Determine the subtotal score for each section, then determine the total scores for sections A-C and C-E. Some questions may appear redundant between sections. There’s a reason for each question. Don’t spend much time on any one question.

    0 = Never true 1= Seldom true 2= Sometimes true 3= Often true

    When under stress for two weeks or longer, I…

    Section A

    1. Get wound up when I get tired and have trouble calming down

    2. Feel driven, appear energetic, but feel “burned out” and exhausted

    3. Feel restless, agitated, anxious, and uneasy

    4. Feel easily overwhelmed by emotion

    5. Feel emotional—cry easily or laugh inappropriately

    6. Experience heart palpitations or a pounding in my chest

    7. Am short of breath

    8. Am constipated

    9. Feel warm, overheated, and dry all over

    10. Get mouth sores or sore tongue

    11. Get hot flashes

    12. Sleep less than seven hours a night

    13. Have trouble falling asleep and staying asleep

    14. Worry about high blood pressure, cholesterol, and triglycerides

    15. Forget to eat and feel little hunger

    Total Points Section A:

    Section B

    1. Find myself worrying about things big and small

    2. Feel like I can’t stop worrying, even though I want to

    3. Feel impulsive, pent up, and ready to explode

    4. Get muscle spasms

    5. Feel aggressive, unyielding, or inflexible when pressed for time

    6. See, hear, and smell things that others do not

    7. Stay awake replaying the events of the day or planning for tomorrow

    8. Have upsetting thoughts or images enter my mind again and again

    9. Have a hard time stopping myself from doing things again and again, like checking on things or rearranging objects over and over

    10. Worry a lot about terrible things that could happen if I’m not careful

    Total Points Section B:

    Section C

    1. Have muscle and joint pains

    2. Have muscle weakness

    3. Crave salt or salty things

    4. Have multiple points on my body that when touched are tender or painful

    5. Have dark circles under my eyes

    6. Feel a sudden sense of anxiety when I get hungry

    7. Use medications to manage pain

    8. Get dizzy when rising or standing up from a kneeling or sitting position

    9. Have diarrhea or bouts of nausea with or without vomiting for no apparent reason

    10. Have headaches

    Total Points Section C:

    Section D

    1. Have trouble organizing my thoughts

    2. Get easily distracted and lose focus

    3. Have difficulty making decisions and mistrust my judgment

    4. Feel depressed and apathetic

    5. Lack the motivation and energy to stay on task and pay attention

    6. Am forgetful

    7. Feel unsettled, restless, and anxious

    8. Wake up tired and unrefreshed

    9. Experience heartburn and indigestion

    10. Catch colds or infections easily

    Total Points Section D:

    Section E

    1. Feel tired for no apparent reason

    2. Experience lingering mild fatigue after exertion or physical activity

    3. Find it difficult to concentrate and complete tasks

    4. Feel depressed and apathetic

    5. Feel cold or chilled—hands, feet, or all over—for no apparent reason

    6. Have little or no interest in sex

    7. Sweat spontaneously during the day

    8. Feel puffy and retain fluids

    9. Sleep more than nine hours a night

    10. Have poor muscle tone

    11. Have trouble losing weight

    12. Wake up tired even though I seem to get plenty of sleep

    13. Have no energy and feel physically weak

    14. Am susceptible to colds and the flu

    15. Feel dragged down by multiple symptoms, such as poor digestion and body aches

    Total Points Section E:

    Add points from sections A, B, & C
    Total for A, B, & C:

    Add points from sections C, D, & E
    Total for C, D, & E:

    Lifestyle and Health Status:

    1. Select the level of stress you experience on the scale of 1-10, 10 being the worst:

    2. What do you consider to be the major causes of your stress (for example—spouse, family, friends, work, finances, wedding, pregnancy, legal, commute):

    3. I eat breakfast times a week.
    My typical breakfast is:

    4. I take a multiple vitamin/mineral days per week. I take a fish oil supplement days per week.

    5. I participate in 30 minutes of physical activity such as walking, aerobics (e.g., running), resistance training (e.g., weights, pilates),
    sports (e.g. biking), or yoga:

    6. I smoke cigarettes daily.

    7. I drink two or more 8 ounce cups of caffeinated coffee or other caffeinated beverages like energy/diet drinks, colas, or black or green teas:

    8. I drink two or more ounces of alcoholic beverages:

    9. List your current health problems and any over-the-counter or prescription medications that you are now taking:

    List all current medication(s)

    Sign up for our newsletter

    Newsletter Form

    This field is for validation purposes and should be left unchanged.