INDEX OF REACTIVITY TO STRESS

Date :...../...../....... Name and Age :................... 1. Restlessness, inability to relax and be calm. Nothing A little Moderately Quite Very or extremely 2. Loss of appetite. Nothing A little Moderately Quite Very or extremely 3. Ignore the problem and think of something else. Nothing A little Moderately Quite Very or extremely 4. Want to sigh, chest tightness, shortness of breath. Nothing A little Moderately Quite Very or extremely 5. Palpitations, Tachycardia. Nothing A little Moderately Quite Very or extremely 6. Feelings of depression and sadness. Nothing A little Moderately Quite Very or extremely

7. Increased need for food, increased appetite. Nothing A little Moderately Quite Very or extremely 8. Trembling, twitching or muscle cramps. Nothing A little Moderately Quite Very or extremely 9. Increased activity. Nothing A little Moderately Quite Very or extremely 10. Nausea, dizziness, unsteadiness. Nothing A little Moderately Quite Very or extremely 11. Effort to think and remain calm. Nothing A little Moderately Quite Very or extremely 12. Tingling or numbness in the hands, face, etc. .. Nothing A little Moderately Quite Very or extremely 13. Upset stomach, abdominal pain, etc. .. Nothing A little Moderately Quite Very or extremely

14. Headaches. Nothing A little Moderately Quite Very or extremely 15. Enthusiasm, energy and enjoy greater status. Nothing A little Moderately Quite Very or extremely 16. Decreased activity. Nothing A little Moderately Quite Very or extremely 17. Loss of sexual desire or sexual difficulties. Nothing A little Moderately Quite Very or extremely 18. Tendency to blame someone or something. Nothing A little Moderately Quite Very or extremely 19. Drowsiness or increased need for sleep. Nothing A little Moderately Quite Very or extremely 20. Apprehension, feeling be getting sick. Nothing A little Moderately Quite Very or extremely

21. Exhaustion or excessive fatigue. Nothing A little Moderately Quite Very or extremely 22. Frequent urination. Nothing A little Moderately Quite Very or extremely 23. Scratching, biting my nails, rubbing, etc. .. Nothing A little Moderately Quite Very or extremely 24. Feelings of aggression or increased irritability. Nothing A little Moderately Quite Very or extremely 25. Diarrhea. Nothing A little Moderately Quite Very or extremely 26. Drinking, smoking or drinking something (gum, lozenges, etc.).. Nothing A little Moderately Quite Very or extremely 27. Need to be alone without anyone bothering me. Nothing A little Moderately Quite Very or extremely

28. Increased sexual appetite. Nothing A little Moderately Quite Very or extremely 29. Anxiety, more prone to fear, fears, etc. .. Nothing A little Moderately Quite Very or extremely 30. Tendency to repeatedly check if everything is in order. Nothing A little Moderately Quite Very or extremely 31. Greater difficulty sleeping. Nothing A little Moderately Quite Very or extremely Result Vegetative Index: Emotional Index: Cognitive Index: Behavioral Index I.R.E. Total: Comments :................................................ ...................................