The information you provide here will be shared with your Health Stewardship Coach. The goal of this assessment is to help you better understand your own thoughts and motivation and give your coach information that will assist them in supporting you as you work to optimize your personal health.

Name *
Name
Stress *
Minor problems throw me for a loop.
Stress *
I find it difficult to get along with people I used to enjoy.
Stress *
Nothing seems to give me pleasure anymore.
Stress *
I am unable to stop thinking about my problems.
Stress *
I feel frustrated, impatient, or angry much of the time.
Stress *
I experience feelings of tension and anxiety.
Stress *
During the past month, I have accomplished less than I would like in my work or other daily activities as a result of emotional issues, such as feeling depressed or anxious.
Stress *
During the past month, my physical health or emotional issues have interfered with my normal social activities with my normal social activities with family, friends, neighbors, or groups.
Stress
I have suffered a personal loss or misfortune in the past year. (For example: a job loss, disability, divorce, separation, or the death of someone close to you.)
Stress *
I am coping well with my current stress load.
Feelings *
I feel calm and peaceful.
Feelings *
I have a lot of energy.
Feelings
I am a happy person.
Feelings *
I take the time to relax and have fun daily.
Feelings *
I feel downhearted or blue.
Feelings *
I feel worthless, inadequate, or unimportant.
Sleep *
I get 7-8 hours of sleep at night.
Readiness for Change *
My readiness to make changes or improvements in my stress level is (please mark one):
Confidence *
My confidence in my ability to make a positive change regarding my stress level is:
Priority *
My confidence in my ability to make a positive change regarding my stress level is:
Understanding *
While we never share your information with any 3rd parties, please be advised that the submission and storage of information you provide through this form is not considered secure. Please do not provide any protected health information through this form. If you would prefer to complete a paper version of this form, please contact our office at info@indeedwellness.com.