Your Mental Health Questionnaire
This questionnaire will show how stress affects different parts of your life. Circle the response which best indicates how often you experience each stress indicator during a typical week. When you have answered all the questions add the point totals for each section.

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Your Mental Health
Mental health means striking a balance in all aspects of your life: social, physical, spiritual, economic and mental. Reaching a balance is a learning process. At times, you may tip the balance too much in one direction and have to find your footing again. Your personal balance will be unique, and your challenge will be to stay mentally healthy by keeping that balance.
In this section, you will find information and suggestions to help you keep your balance.
Anger
Feelings of anger are a normal reaction to some situations beyond your control. They can also indicate that you are simply under too much stress, and it can be hard to know if you should just let your anger pass or work at getting rid of it.
All of us feel angry, at least occasionally. Most of the time when we get angry, we get over it quickly because, somehow, we resolve the situation and our feelings of anger pass. Anger becomes a problem, however, if we “bottle it up” or if we “blow up.” Both of these extremes cause problems for the angry people and for those around them.
In this section, you will find information that will help you manage problematic anger in a healthy way.
Feeling Angry
We all feel angry sometimes. Most of the time, we can deal with feelings of anger or irritability quickly. We may resolve the situation or look at the problem from a different perspective. However, anger can cause problems in our lives and the lives of those around us. Learn more about recognizing problem anger and taking action.
Longer-term solutions These strategies take more time and effort, but they can help you cope with anger as it comes up in many different situations. The goal is to change the way you react to anger so it doesn’t cause problems in the first place. • Learn what triggers your anger. Some people are triggered by other people, such as a boss, friend, or family member. Certain emotions, such as feeling controlled, ashamed or guilty, can also trigger anger for some people. • Identify your early warning signs so you can take action before your anger turns into fullblown rage. Common early warning signs include a pounding heart, tight chest or jaw, feeling resentful or irritated, or feeling like lashing out. • Talk to someone you trust who may be able to see things more clearly than you do. Remember that anger can tell us we need to solve a problem. Another person can help you practice identifying the real problem, brainstorming solutions, and testing solutions out. • If your anger is caused by something beyond your control, such as a job loss, learn how others have dealt with a similar problem successfully and try their strategies. • Learn and practice skills like healthy thinking, problem solving and stress management. All of these can help manage anger. • Many people find physical activity very helpful. Try going for a walk, playing your favourite sport, or cleaning the house. • Make sure you eat well and get enough sleep. We often lose patience and get irritated more easily when we’re tired or hungry. • Learn mindfulness practices like meditation. Mindfulness teaches you how to look at your thoughts in the present moment without judgment. It may also help teach you to tolerate angry feelings without pushing them away. • Learn more about assertiveness. Anger can persist when we avoid talking directly to someone about something that has made us angry. Assertiveness is a way of telling others what you feel or what you need while respecting their feelings or needs. • If you feel easily frustrated when people don’t act the way you want them to, remember that you cannot control how other people behave. You can only control how you choose to react to those behaviours. Anger and irritability can sometimes be signs of depression or anxiety. If anger continues to cause problems or you notice that anger occurs with other symptoms, it’s a good idea to talk with a doctor or mental health professional.
PHYSICAL *
How often would you say: 5- Almost Always (on five days a week) 4- Most of the time (on three days a week) 3- Some of the time ( on one and one-half days a week) 2- Almost never (less than two hours a week) 1- Never
1
2
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5
My body feels tense all over.
I have a nervous sweat or sweaty palms.
I have a hard time feeling really relaxed.
I have severe or chronic lower back pain.
I get severe or chronic headaches.
I get tension or muscle spasms in my face, jaw, neck or shoulders.
My stomach quivers or feels upset.
I get skin rashes or itching.
I have problems with my bowels (constipation, diarrhea).
I need to urinate more than most people.
My ulcer bothers me.
I feel short of breath after mild exercise like climbing up four flights of stairs.
Compared to most people, I have a very small or a very large appetite.
My weight is more than 15 pounds higher than what is recommended for a person my height and build.
I smoke tobacco.
I get sharp chest pains when I'm physically active.
I lack physical energy.
When I'm resting, my heart beats more than 100 times a minute.
Because of my busy schedule I miss at least two meals during the week.
I don't really plan my meals for balanced nutrition.
I spend less than 3 hours a week getting vigorous physical exercise (running, playing basketball, tennis, swimming, etc).
Physical Indicators Point Total
SLEEP *
How often would you say: 5- Almost Always (on five days a week) 4- Most of the time (on three days a week) 3- Some of the time ( on one and one-half days a week) 2- Almost never (less than two hours a week) 1- Never
1
2
3
4
5
I have trouble falling asleep.
I take pills to get to sleep.
I have nightmares or repeated bad dreams.
I wake up at least once in the middle of the night for no apparent reason.
No matter how much sleep I get, I awake feeling tired.
Sleep Indicators Point Total
BEHAVIORAL *
How often would you say: 5- Almost Always (on five days a week) 4- Most of the time (on three days a week) 3- Some of the time ( on one and one-half days a week) 2- Almost never (less than two hours a week) 1- Never
1
2
3
4
5
I stutter or get tongue tied when I talk to other people.
I try to work while I'm eating lunch.
I have to work late.
I go to work even when I feel sick.
I have to bring work home.
I drink alcohol or use drugs to relax.
I have more than two beers, eight ounces of wine or three ounces of hard liquor a day.
When I drink, I like to get really drunk.
I get drunk or "high" with other drugs more than once a week.
When I'm feeling high from alcohol or drugs I will drive a motor vehicle.
I tend to stumble when walking, or have more accidents than other people.
In any given week, I take at least one prescription drug without the recommendation of a physician, e.g. amphetamines, barbiturates.
I have problems with my sex life.
At least once during the week I will make bets for money.
After dinner I spend more time alone or watching TV than I do talking with my family or friends.
I arrive at work late.
At least once during the week I have a shouting match with a co-worker or supervisor.
Behavior Indicators Point Total
EMOTIONAL *
How often would you say: 5- Almost Always (on five days a week) 4- Most of the time (on three days a week) 3- Some of the time ( on one and one-half days a week) 2- Almost never (less than two hours a week) 1- Never
1
2
3
4
5
I have found the best way to deal with hassles and problems is to consciously avoid thinking or talking about them.
I have trouble remembering things.
I feel anxious or frightened about problems I can't really describe.
I worry a lot.
It is important for me not to show my emotions to my to my family.
It is hard for me to relax at home.
It's best if I don't tell even my closest friend how I'm really feeling.
I find it hard to talk when I get excited.
I feel very angry inside.
I have temper outbursts I can't control.
When people criticize me, even in friendly, constructive way, I feel offended.
I feel extremely sensitive and irritable.
My emotions change unpredictably and without any apparent reason.
I feel like I really can't trust anyone.
I feel like other people don't understand me.
I really don't feel good about myself.
Generally I am not optimistic about my future.
I feel very tired and disinterested in life.
Impulsive behavior has caused me problems.
I have felt so bad that I thought of hurting myself.
When I have an important personal problem I can't solve myself, I do not seek professional help.
Emotional Indicators Point Total
PERSONAL HABITS *
How often would you say: 5- Almost Always (on five days a week) 4- Most of the time (on three days a week) 3- Some of the time ( on one and one-half days a week) 2- Almost never (less than two hours a week) 1- Never
1
2
3
4
5
I spend less than three hours a week working on a hobby of mine.
I spend less than one hour a week writing personal letters, writing in a diary or writing creatively.
I spend less than 30 minutes a week talking casually with my neighbours.
I lack time to read the daily newspaper.
I watch television for entertainment more than one hour a day.
I drive in a motor vehicle faster than the speed limit for the excitement and challenge of it.
I spend less than 30 minutes a day working toward a life goal or ambition of mine.
My day to day living is not really affected by my religious beliefs or my philosophy of life.
When I feel stressed, it is difficult for me to plan time and activities to constructively release my stress.
Personal Habits Point Total
Notes
Note the areas where you showed "very high" or "danger" levels of stress. These are problem areas you should focus on when you develop your Personal Stress Management Plan. If you have no points totals in the "very high" or "danger" zones, congratulations- you are doing a very good job of managing stress.
In your Personal Stress Management plan, focus on:
1) building stress resources and
2) stress prevention through aerobic exercise, yoga, relaxation, nutrition and sleep.
Early Warning Signs
On the lines below, write the three signs which occur earliest and most regularly when you're under stress. You may want to look back at your questionnaire to get an idea of what your early warning signs are. These signs give advance notice of being stressed and allow you to identify what causes you stress, and to take action before serious problems result.
1.
Your answer
2.
Your answer
3.
Your answer
Date Questionnaire Completed
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