Alex Gellman: Stress Form

Stress Age Questionnaire

Research centres around the world are reporting that even though we are in the electronic computer age, the individual is suffering from more stress than ever before. What does stress do to your body? In one simple answer, it ages us before our time.

Try to answer the questions as accurately and honestly as possible. Note that this is only a guideline to give the individual insight as to what areas of your life need changes. The questionnaire is divided into seven sections: Chronological Age, Dietary Choices, Daily Activities, Medical History, Medication, Stress, and Life Balance.

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A. Chronological Age
1. What is your current age (in years)?
B. Dietary Choices
2. How frequently do you eat fried, broiled, or barbequed foods? Often Once a day Few times per week Once a week Almost Never
3. How often do you consume nutritional oils (not heated, i.e. flax, hemp, omega3,6,9)? Never Once a week Once a day 2+times per day
4. How many servings of fruits or vegetables do you consume? Almost never few times a week once a day 3 per day 5+per day
5. How often do you consume whole grains and/or natural fibre? Almost never Once a week few times per week often
6. How many glasses of water do you consume daily? (water does not include coffee, black tea, soda, and alcohol) almost never 1 to 3 glasses 4 to 6 glasses 6 to 8 glasses more than 9
7. Do you consume sugar, soda, white flour, or other processed foods? (eg: canned foods, fast food, TV dinners, foods with preservatives added) 3+times/day once a day few times a week once a week almost never
8. How many alcoholic drinks do you consume per week? 12+/week 8/week 4/week 2/week almost never
9. How often do you add salt to your food? All Food daily few times per week once a month almost never
C. Daily Activities
10. Do you exercise (30 or more minutes of continuous activity)? Almost never once/week 3x/week 5+/week
11. When you exercise, do you do so for more than 2 hours? (if you do not exercise, put "almost never" as your answer) Most times 50% of the time almost never
12. Do you sleep well and awake rested? Almost never sometimes usually always
13. How many bowel movements do you have per day? Few times per week every other day once/day 2/day 3+ per day
D. Medical History
14. Is there a history of the following conditions in your family? Cancer, diabetes, heart disease, depression, obesity, liver disease, high cholesterol, high blood pressure 2 or more one none
15. Have you ever had any of the following: cancer, diabetes, heart disease, depression, obesity, liver disease, high cholesterol, high blood pressure 2 or more one none
16. How frequently do you experience the following conditions: headache, fever, sore throat, muscle aches (not exercise induced) colds or flu, rash, swelling? Once a day once a week once a month almost never
17. Have you ever been exposed to heavy metals or toxic substances? (eg: mechanics, hairdressers, nail technician, hair dye, false nails, cleaning products) daily weekly monthly almost never
18. Have you ever been exposed to heavy metals via dental work or fillings? (eg. Mercury fillings or other metal in the mouth) 3+ 2 1 nothing in mouth/never
E. Medication
19. How many over the counter medications have you taken in the last 6 months? 4+ 2+ occasionally almost never never take any
20. How many prescription antibiotics have you taken in the last 12 months? (including birth control) 4+ 2+ 1 None
F. Stress
21. How many full meals do you eat per day? (a snack is not a full meal) No Meals 3 meals and a snack 3 meals 2 meals 1 meal
22.How often are you exposed to cigarette smoke (direct or second hand) all day few times few times per week almost never
23. Do you use recreational or street drugs? 2+times per day 1x/day 1x/week 1x/month never
24. Do you drive in heavy traffic? For a living daily (3+hours) daily (1-2hrs) almost never
25. At work and/or at home, do you experience stress? Very high high moderate slight almost none
26. Has there been any major traumatic event in your life in the past 10 years? (e.g. death of a loved one, divorce, job loss, bankruptcy, major illness of a loved one/chronic care) 3+ 2 1 none
G. Life Balance
27. Do you watch Television or surf the internet for more than 2 hours? Yes No
28. Do you pursue a creative outlet? Yes No
29. Do you meditate or take time to still the mind? Yes No
30. Do you often drive faster than the posted speed limit ? Yes No
31. Do you engage in some form of escape? Escape is simply not being present and using stimulation to keep a high and not be present examples are: gambling, internet, porn, eating, shopping, over work, alcohol, drugs, smoking? Yes No
32. Do you pursue working with a health care holistic practitioner? Yes No
33. Do you pursue some form of body work? Yes No
34. At home or work, how often are you in front of electronic equipment? 8+ hours 6+ hours few hours almost never
35. Are you overweight based on BMI scale? No by 5 pounds by 10 pounds by 15 pounds by 20 or more pounds

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Stress Age Questionnaire

Contact Details

A. Chronological Age

B. Dietary Choices

C. Daily Activities

D. Medical History

E. Medication

F. Stress

G. Life Balance