Stress comes in many different forms. This stress test is adapted from the "Social Readjustment and Rating Scale by Thomas Holmes and Richard Rahe" published in the "Journal of Psychosomatic Research."

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* 1. In the last year, I have experienced the loss a loved one. Select all that impact you.

Spouse / Partner

Parent

Child

Immediate Family Member

Pet

Distance Relative

Close Friend (not a relative)

Co-Worker

Acquaintance

Idol, Mentor, Teacher

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* 2. In the last year, I have experienced or am still impacted by:

Divorce

Major breakup / separation from living partner

Change in number of arguments with partner

Trouble with children or in-laws

Marriage or establishing life partnership

Relationship or marriage reconciliation

Gain of a new family member (pregnancy, adoption, other...)

Frequency of family get togethers (more or less than before)

Living conditions (remodel, visitors, roommates, etc).

Moving to a new residence

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* 3. In the last year, I have experienced or am still impacted by:

Change of health in immediate family member

Serious personal injury or illness

Legal ramifications (jail term, probation, bankruptcy, major legal battle, custody battle, other...)

Minor violation of the law (parking, speeding ticket, car accident, etc.)

Change in personal health habits (diet, exercise, smoking, etc).

Change in religious activities

Change in social activity (more or less than before)

Bedroom difficulties, hormonal life changes

Chronic allergies

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* 4. In the last year, I have experienced or my work has been impacted by:

Outstanding personal achievement

Change in financial state (for better or worse)

Loss of income (fired, laid off, unemployed, retired)

Working more than 40 hours per week, change in hours or conditions

Business or work role change, change in responsibilities

Trouble with boss

Mortgage or loan for major purposes

Foreclosure on mortgage or loan

Minor financial loan

No vacation in last 12 months

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* 5. Presently, I'm experiencing:

Winter holiday season

Beginning or ending school

Changing schools

Other (please specify)

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* 6. Do you have any other comments, questions, or concerns?

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* 7. I give permission for Jessica to contact me with my results.

Name *

State/Province

Country

Email Address *

Phone Number *