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Mood and Stress Questionnair
Please read each question or statement and place a circle in the column which indicates how much the question or statement applied to you over the past few weeks. There are no right or wrong answers. It is best not to spend too much time on any question. Some questions are repeated, please answer them all.
SECTION 1
5. Do you fi nd it hard to make decisions? 6. Would you describe yourself as introverted? 10. Does your heartbeat feel irregular, where you are 13. Are you forgetful, or have a poor memory? 14. Do you tend to brood over and over the same concerns?
SECTION 2
1. Do you feel quite unmotivated at times, or feel like you 2. Do you feel you have a poor memory, or are you quite 3. How often does poor mental function affect your ability 4. Do you forget things like names, dates or facts easily? 5. Do you fi nd it very diffi cult to concentrate? 6. Do you feel physically lethargic or fatigued? 7. Do you feel mentally lethargic or fatigued? 8. Do you fi nd it diffi cult to learn new things? 10. Do you repeatedly reach for coffee, tea, sweets or other 11. Do you have chronic aches and pains? 12. Do you have an increased sensitivity to pain? 13. Do you fi nd it diffi cult if people talk to you when you’ve 14. Do you struggle with mental tasks which you used to fi nd SECTION 3
1. Do you feel irritated or frustrated easily? 2. Do you let out a sigh at least a few times a day? 3. Do you fi nd it hard to get to sleep or stay asleep? 4. Do you have shoulder and neck pain or stiffness? 6. Do you have a tendency to be irritable or grumpy in 8. Do you skip some meals and/or eat excessively at 9. Do you feel nauseous or get refl ux when stressed? 12. Do you suffer from PMS - tender breasts, lumps in the breast or moodiness before your period? 13. Are you suffering from menopausal symptoms or 14. Do you have an irritable bowel - excessive bloating, 15. Do you have a short fuse or a quick temper? 16. Do you have an irritable bowel - excessive bloating, 17. Do you have a short fuse or a quick temper? SECTION 4
1. Do you feel irritated or frustrated easily? 2. Do you feel you have extremes of emotion? 3. Do things easily trigger you to explode with anger or 4. Do you fi nd it hard to get to sleep or stay asleep? 5. Do you tend to over-react to situations? 7. Would you consider yourself a risk-taker, in your work or 9. Do you suffer from muscle tightness, cramps, and spasms? 11. Do you drink alcohol or use other drugs to relieve stress 12. Do you feel so angry at times that you feel like you might 13. Do you suffer from heartburn, gastritis or refl ux? 14. Are your bowel movements diffi cult or infrequent? 15. Do you feel you have a short fuse or a quick temper? SECTION 5
2. Do you fi nd it diffi cult to fall asleep? 3. Do you wake early in the morning and fi nd it hard to get 5. Do you feel restless, fi dgety or unable to sit still? 7. Do you have a restless, overactive mind? 8. Do you tend to lose weight when stressed or depressed? 9. Does your appetite tend to decrease with stress or 10. Do you have a tendency to addictions or substance abuse? SECTION 6
5. Do you have diffi culty completing projects? 6. Do you tend to avoid facing problems? 8. Do you fi nd it diffi cult to lose weight? 11. Do you have a lack of interest in sex? 12. Do you suffer from infertility or impotence? 13. Does your appetite increase when you are stressed or SECTION 7
3. Do you feel very fatigued in the afternoon or night? 4. Do you feel fl ushed, hot or sweating in the afternoon 5. Do you get very thirsty, or have a dry throat? 6. Have you been anxious or worried for many years? 8. Does your mind feel restless, like you can’t shut it down? 9. Do you wake at 3-4am in the morning and fi nd it diffi cult 11. Are you forgetful, or have a poor memory? 12. Do you have aches and pains in your bones, joints or 13. Are your bowel movements diffi cult, hard, dry or infrequent? SECTION 8
1. Do you feel irritated or frustrated easily? 3. Do you fi nd it hard to get to sleep or stay asleep? 5. Do you crave sugary, fatty or starchy foods? 8. Do you suffer from migraines or headaches? SECTION 9
3. Do you lack motivation, or feel like you can’t be bothered? 4. Do you have digestive problems which worsen with stress? 5. Do you suffer from indigestion, refl ux, nausea, vomiting, or 6. Do you suffer from allergies – sneezing, rash, eczema, etc? 9. Do you need to clear your throat regularly throughout the 10. Do you have a feeling of tightness or obstruction in the SECTIONS 1-4
NEUROLOGICAL AND HORMONAL PATTERN
• Add up the scores for each section and transfer the totals into the ‘Score’ column on this sheet• Rank each section based on the score in descending order, ie. ‘1’ is the top score, ‘2’ is the second-highest • Rank 1 indicates the most relevant prescription for your patient in this category• If the top scores are quite close together, have a look at the questions in those sections. The section which takes priority is that which addresses the most relevant clinical concerns for your patient Section Score Catchphrase
Ginseng Complex for Emotional Resilience Bupleurum Complex for Nervous Tension and Irritability Bupleurum and Calcium Complex for Stress and Insomnia SECTIONS 5-7
COMMON STRESS-RELATED COMPLAINTS
• Follow the instructions above to complete the score sheet below• Rank 1 indicates the most relevant prescription for your patient in this category Section Score Catchphrase
Herbal Support for Hyper HPA and Stress Herbal and Nutritional Support for Adrenal Health Rehmannia Complex for Nervous Exhaustion SECTIONS 8-9
DEPRESSION SUPPORT
• This section should be utilised where specifi c treatment for depression is required - diagnosed or self- reported depression, or high score in the depression section of the DASS42 questionnaire • This section assists the selection of the most relevant prescription for depression• This section will not identify depression in patients - for this purpose, use the DASS42 questionnaire in • Use the same method for calculating the scores as described above - in this case, there will only be rank ‘1’ Section Score Catchphrase
Pinellia and Hypericum Complex for Healthy Mood

Source: http://www.ahwb.com.au/assets/files/moodStressQuestionaire.pdf