Exam Survey Pilot Testing
Rate how often you feel each statement and how severe each symptom is.
STRESS FREQUENCY GRID For each statement, select how often it applies to you.
*
Rows
Never (1)
Seldom (2)
Sometimes (3)
Often (4)
Very Often (5)
I feel rested
1
2
3
4
5
I feel that too many demands are being made on me
6
7
8
9
10
I have too many things to do
11
12
13
14
15
I feel that I am doing things I really like
16
17
18
19
20
I fear I may not manage to attain my goals
21
22
23
24
25
I feel calm
26
27
28
29
30
I feel frustrated
31
32
33
34
35
I am full of energy
36
37
38
39
40
I feel tense
41
42
43
44
45
My problems seem to be piling up
46
47
48
49
50
I feel that I am in a hurry
51
52
53
54
55
I feel safe and protected
56
57
58
59
60
I have many worries
61
62
63
64
65
I enjoy myself
66
67
68
69
70
I am afraid for the future
71
72
73
74
75
I am lighthearted
76
77
78
79
80
SYMPTOM SEVERITY GRID For each symptom, select the severity you have experienced recently.
*
Rows
None (1)
Mild (2)
Moderate (3)
Severe (4)
Very Severe (5)
Stomach Pain — Pain in the area between the bottom of your ribs and your hips.
81
82
83
84
85
Back Pain — Discomfort anywhere along the back of your body, from the base of your neck to the top of your butt.
86
87
88
89
90
Headaches — Pain in your head or face, often described as pressure, throbbing, constant, sharp, or dull.
91
92
93
94
95
Chest Pain — Any ache, pressure, tightness, or burning feeling in the front of your body between your neck and upper abdomen.
96
97
98
99
100
Dizziness — Feeling woozy or lightheaded, or feeling as if you need to sit down before you fall down.
101
102
103
104
105
Increased Heart Rate — Feeling like your heart is racing, pounding, skipping, or missing beats.
106
107
108
109
110
Difficulty Breathing — Feeling like you cannot get enough air into your lungs, chest tightness, gasping, or working harder to breathe.
111
112
113
114
115
Constipation or Diarrhea — Constipation is hard, infrequent, or painful stools. Diarrhea is loose, watery stool during a bowel movement.
116
117
118
119
120
Difficulty Sleeping
121
122
123
124
125
Skin Irritation — Skin feels uncomfortable, itchy, sore, inflamed, or red.
126
127
128
129
130
Submit
Should be Empty: