Stress & Burnout
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1. Factors in Stress & Burnout

1. External Factors:
Please evaluate the following stress related external factors that could contribute to burnout, and rate the impact of their occurrence in your life this past year.

	None	Low	Medium	High
Recent Move	*External Factors: Please evaluate the following stress related external factors that could contribute to burnout, and rate the impact of their occurrence in your life this past year. Recent Move None	Recent Move Low	Recent Move Medium	Recent Move High
Social Isolation	Social Isolation None	Social Isolation Low	Social Isolation Medium	Social Isolation High
Financial Difficulties	Financial Difficulties None	Financial Difficulties Low	Financial Difficulties Medium	Financial Difficulties High
Relationship Change	Relationship Change None	Relationship Change Low	Relationship Change Medium	Relationship Change High
Marital Conflict	Marital Conflict None	Marital Conflict Low	Marital Conflict Medium	Marital Conflict High
Family Adjustments	Family Adjustments None	Family Adjustments Low	Family Adjustments Medium	Family Adjustments High
Separation / Divorce	Separation / Divorce None	Separation / Divorce Low	Separation / Divorce Medium	Separation / Divorce High
Work Difficulties	Work Difficulties None	Work Difficulties Low	Work Difficulties Medium	Work Difficulties High
Time Pressures / Overload	Time Pressures / Overload None	Time Pressures / Overload Low	Time Pressures / Overload Medium	Time Pressures / Overload High
Death of a Loved One	Death of a Loved One None	Death of a Loved One Low	Death of a Loved One Medium	Death of a Loved One High
Traumatic Event	Traumatic Event None	Traumatic Event Low	Traumatic Event Medium	Traumatic Event High
Other	Other None	Other Low	Other Medium	Other High

2. Internal Factors:
Please consider the following internal factors that contribute to stress and/or burnout, and rate their impact in your life this past year.

	None	Low	Medium	High
Anxiety	*Internal Factors: Please consider the following internal factors that contribute to stress and/or burnout, and rate their impact in your life this past year. Anxiety None	Anxiety Low	Anxiety Medium	Anxiety High
Anger	Anger None	Anger Low	Anger Medium	Anger High
Difficulty in adjusting	Difficulty in adjusting None	Difficulty in adjusting Low	Difficulty in adjusting Medium	Difficulty in adjusting High
Guilt	Guilt None	Guilt Low	Guilt Medium	Guilt High
Impact of past traumatic experience	Impact of past traumatic experience None	Impact of past traumatic experience Low	Impact of past traumatic experience Medium	Impact of past traumatic experience High
Inability to see a way out	Inability to see a way out None	Inability to see a way out Low	Inability to see a way out Medium	Inability to see a way out High
Inaccurate perceptions	Inaccurate perceptions None	Inaccurate perceptions Low	Inaccurate perceptions Medium	Inaccurate perceptions High
Lack of self trust / esteem	Lack of self trust / esteem None	Lack of self trust / esteem Low	Lack of self trust / esteem Medium	Lack of self trust / esteem High
Lack of trust in others	Lack of trust in others None	Lack of trust in others Low	Lack of trust in others Medium	Lack of trust in others High
Lack of trust in God	Lack of trust in God None	Lack of trust in God Low	Lack of trust in God Medium	Lack of trust in God High
Lack of self care (eating/sleeping)	Lack of self care (eating/sleeping) None	Lack of self care (eating/sleeping) Low	Lack of self care (eating/sleeping) Medium	Lack of self care (eating/sleeping) High
Over-conscientiousness	Over-conscientiousness None	Over-conscientiousness Low	Over-conscientiousness Medium	Over-conscientiousness High
People-pleasing	People-pleasing None	People-pleasing Low	People-pleasing Medium	People-pleasing High
Reduced sense of reward	Reduced sense of reward None	Reduced sense of reward Low	Reduced sense of reward Medium	Reduced sense of reward High
Sense of failure	Sense of failure None	Sense of failure Low	Sense of failure Medium	Sense of failure High
Spiritual “slackness”	Spiritual “slackness” None	Spiritual “slackness” Low	Spiritual “slackness” Medium	Spiritual “slackness” High
Violation of personal values	Violation of personal values None	Violation of personal values Low	Violation of personal values Medium	Violation of personal values High
Workaholicism	Workaholicism None	Workaholicism Low	Workaholicism Medium	Workaholicism High

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Stress & BurnoutExit this survey >>

1. Factors in Stress & Burnout

Stress & Burnout
Exit this survey >>