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Life Stress Assessment

For all the following check once for “some” and twice for “a lot”.

Chemical / Physiologic Stress:

I over or under eat O O

I have Incomplete digestion / acid indigestion O O

I have vitamin / mineral deficiencies O O

I have food sensitivities O O

I experience sleep cycle disturbance O O

I live or work in high traffic areas – low oxygen O O

I have allergies (i.e. pollens etc.) O O

I have environmental sensitivities O O

I have bacteria or virus infections O O

I have yeast and fungus infections O O

I have parasites O O

I have mercury fillings /Heavy metals O O

I use or am around pesticides O O

I take medications – Medical drug residues O O

I use recreational drugs O O

I use alcohol, tobacco O O

I am exposed to excess heat or cold O O

I drink treated city water O O

I use antiperspirants that contain aluminum O O

I use plug-in air fresheners O O

I use several medications – drug interactions O O

I have been Immunized O O

Diet Stress:

I use artificial food additives or sweeteners O O

I use fried foods – Rancid fats (free radicals) O O

I use packaged foods – Partially hydrogenated oils O O

I use vegetable/ seed/ polyunsaturated oils O O

I use sugary snacks (diabetes/ insulin resistance) O O

I use milk (hormone excessesand heart damage) O O

I use flour products (excitotoxins/ gut inflammation)O O

I use soy products (hormone imbalances) O O

I use MSG (brain damage causing) O O

I use salty snacks (hydration dysregulation) O O

I drink water with my meals (poor digestion) O O

I drink more than 1 serving of alcohol per day O O

I binge eat O O

I purge O O

I skip meals O O

I diet a lot O O

I skip eating my vegetables O O

I eat fast food (Contaminated food) O O

Psychological / Energetic Stresses:

1. Emotional Stresses:

Family issues / stress O O

Parenting-new & continuing O O

Work / bosses or co-workers O O

Money / taxes / etc. O O

Relationships (most aspects) O O

Past / regret or guilt O O

Future / worry / conjecture O O

Aging – too much or too little O O

Social stress / peer interactions O O

Self worth / esteem O O

Pursuit of love O O

Inappropriate anger O O

Excessive attention need O O

Death / loss / grief / divorce O O

Sudden change – good or bad O O

Fear / phobias / anxiety O O

Social order / ethics / politics O O

Sex and gender concerns O O

Addictions & using O O

Obsessive-compulsive behaviors O O

Survival concerns O O

Authority issues O O

Victim experience O O

Over concern for others O O

Dependency issues/ growing up O O

2. Mental Stresses:

Negative attitudes / beliefs /superstitions O O

Time & goal management issues O O

Need for control O O

Negative habits O O

Unrealistic expectations / immaturity O O

Information overload O O

Recent bad news / shock O O

Old unresolved traumas O O

Judging or being judged O O

Blocked expression O O

Subconscious / conscious inhibitions O O

Negative subconscious beliefs O O

Poor life skill development O O

Assumptions & faulty logic O O

Conflicting desires or wants O O

Poor boundaries / sense of self O O

Deficient assertiveness skills O O

False desire implantation-(advertising) O O

Negative imagery exposure-(violence on TV etc.) O O

3. Energetic Stresses:

Electro-magnetic pollution (EMFs) O O

Aesthetic deprivation (lack of beauty) O O

Radiation / sunburn O O

Insufficient natural light O O

Acoustic stress (sound or noise) O O

4. Spiritual Stresses:

Disharmony with life O O

Purpose & meaning missing O O

God’s will vs. ego self will O O

Non-acceptance of what is O O

Narcissism / self-centered O O

Attachment to right and wrong O O

No outflow to others O O

Failed connection / participation O O

Structural Functioning Stress:

Traumatic injury (i.e. a fall) O O

Whiplash injury O O

Over exertion / lifting stress O O

Repeated micro-trauma injury O O

Poor workstation ergonomics O O

Not enough exercise / excess sitting O O

Poor muscle tone O O

Balance / coordination problems O O

Joint pain affecting motion O O

Bad posture O O

Weak ligaments O O

Foot / knee problems O O

Subluxations of the spine O O

TMJ (jaw) dysfunction O O

Scars & adhesions O O

Bursitis / tendonitis /Disc inflammation O O

Diaphragm tension O O

Congested lymph glands O O

Stomach / bowel problems O O

Liver or kidney trouble O O

Sinus problems O O

Nerve irritation-inflammation O O

Impaired feeling sensation O O

Visual disturbances O O

Teeth and gum problems O O

Infections/ Overt disease conditions O O

Genetic disorders O O