Stress Hypertension Assessment Form
Stress Hypertension Assessment Form – Please answer the following questions to help assess your risk for stress-related blood pressure concerns.
How often do you experience stress in your daily life?
*
Rarely
Sometimes
Often
Almost always
On average, how would you rate your stress level?
*
1
2
3
4
5
How frequently do you monitor your blood pressure?
*
Never
Occasionally
Monthly
Weekly or more
Have you ever been told by a healthcare provider that you have high blood pressure?
*
Yes
No
Not sure
How many days per week do you engage in physical activity (at least 30 minutes)?
*
0 days
1-2 days
3-4 days
5 or more days
How would you describe your sleep quality?
*
Very poor
Poor
Average
Good
Excellent
Do you have a family history of high blood pressure?
*
Yes
No
Not sure
In the past month, how often have you experienced the following symptoms?
*
Rows
Never
Rarely
Sometimes
Often
Headaches
1
2
3
4
Fatigue
5
6
7
8
Difficulty concentrating
9
10
11
12
Irritability
13
14
15
16
How would you rate your ability to manage stress?
*
Very poor
1
2
3
4
Excellent
5
1 is Very poor, 5 is Excellent
Do you use any of the following methods to cope with stress? (Select all that apply)
*
Physical exercise
Meditation or relaxation techniques
Talking with friends or family
Professional counseling
Hobbies or creative activities
Other
Please share any additional concerns related to stress or blood pressure.
Submit Assessment
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