Mood & Stress Questionnaire

Please complete the following form and submit to us at least 24 hours prior to your Initial Consultation.

Name*
First Last
Email*
Today's Date*
Date Format: DD slash MM slash YYYY
Section 1
I feel "wired but tired" - anxious but lethargic*
I feel restless and exhausted when stressed*
I feel tired all day but then cannot sleep at night or wake early in the morning and cannot get back to sleep.*
I get easily overstimulated by even mild amounts of caffeine or sugar*
Section 2
I feel like my "battery is flat"*
I feel mentally and physically exhausted*
I find it hard to get motivated to start or complete tasks*
I find it hard to get going in the mornings*
Section 3
I feel downhearted and sad*
I find it hard to get enthusiastic about anything*
I find it difficult to work up the initiative to do things*
I see nothing in my future to be hopeful about*
Section 4
I feel anxious and worried*
I feel panicky or distressed*
I find it difficult to relax*
I feel nervous and tense*
Section 5
I get easily irritated, frustrated, grumpy or moody*
It takes me a long time to wind down if something upsets me*
I suffer from shoulder and/or neck pain and/or stiffness*
I find myself getting impatient when I am delayed in any way (e.g. traffic lights, lifts, being kept waiting)*
Section 6
I worry excessively*
I feel teary or cry easily when stressed*
I find it difficult making decisions and/or tend to brood on things from the past*
I feel overwhelmed, like everything is too much to cope with*
Section 7
I find it difficult to fall asleep and/or stay asleep*
I wake unrefreshed*
I find it difficult to relax or "switch off", especially at night*
I feel intense anxiety or panic*
Phone
This field is for validation purposes and should be left unchanged.

Mood & Stress Questionnaire

Section 1

Section 2

Section 3

Section 4

Section 5

Section 6

Section 7