Patient Stress Questionnaire: Assessing Stress, Depression, Anxiety, and Alcohol Consumption | Meta Analysis

Date:_______________ Birthdate_________________
Patient Stress Questionnaire*
Name: __________________________________________
Over the last two weeks , how often have you been bothered by
any of the following problems?
(please circle your answer & check the boxes that apply to you)
Not at all
Several
days
More than
half the
days
Nearly
Every day
1. Little interest or pleasure in doing things 0 1 2 3
2. Feeling down, depressed, or hopeless 0 1 2 3
3. Trouble falling or staying asleep, or
sleeping too much 0 1 2 3
4. Feeling tired or having little energy 0 1 2 3
5. Poor appetite or
overeating 0 1 2 3
6. Feeling bad about yourself or that you are a failure or
have let yourself or your family down 0 1 2 3
7. Trouble concentrating on things, such as reading the
newspaper or watching television 0 1 2 3
8. Moving or speaking so slowly that other people
could have noticed, or
the opposite - being so fidgety or restless that
you've been moving around a lot more than usual
0 1 2 3
9. Thoughts that you would be better off dead, or
hurting yourself in some way 0 1 2 3 Total
(10)
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columns:
1. Feeling nervous, anxious or on edge 0 1 2 3
2. Not being able to stop or control worrying 0 1 2 3
3. Worrying too much about different things 0 1 2 3
4. Trouble relaxing 0 1 2 3
5. Being so restless that it is hard to sit still 0 1 2 3
6. Becoming easily annoyed or irritable 0 1 2 3
7. Feeling afraid as if something awful might happen 0 1 2 3 Total
(8)
*adapted from PhQ 9, GAD7, PC-PTSD and AUDIT 1/24/11
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columns:
Provider:__________________________________ Please also complete back side