Nervous System Questionnaire

Read each of the statements below. In the box to the right of the statement, select a number from 0–3, based on how much the statement applies to you. Use the following key:

[0] = Never applies to me
[1] = Rarely applies to me
[2] = Sometimes applies to me
[3] = Often applies to me

Note: You must answer all the questions below

I feel like I have too much to do and it makes me feel stressed.
I am under a lot of pressure at work and/or at home.
I’ve been facing many difficult situations recently.
I feel overwhelmed by what’s going on in my life.
I don’t get much time to relax.
   
I tend to feel nervous in new situations.
I feel shaky and uneasy sometimes.
I worry about a lot of things.
I have a lot of repetitive stressful thoughts.
I feel anxious in certain situations.
   
I feel discouraged about things that are happening in my life.  
I want to sleep a lot.
I have a hard time getting excited or motivated.
I feel tired and perhaps a little bit sad.
I tend to slouch when I sit or stand.
   
It’s hard for me to unwind and relax.  
It’s hard to go to sleep because there is so much on my mind.
I have a lot of tense muscles.
I tend to stay up late at night.
I sometimes have a hard time getting to sleep.

 


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