| Sources of Stress (Specific) | Not at all Stressful 1 | Kind of Stressful 2 | Clearly Stressful 3 | Majorly Stressful 4 | Severely Stressful 5 |
| Physical health (illness, injury, disease, capacity, endurance, resilience) |
| | | | | | |
| Mental Capacity (memory, attention, concentration, thinking, focus) |
| | | | | | |
| Emotional Health (worry, sadness, anger, frustration, anxiety, depression) |
| | | | | | |
| Spiritual Capacity (faith, spirituality, connection to a higher power) |
| | | | | | |
| Partner relationship (spouse, partner, boy/girlfriend, best friend) |
| | | | | | |
| Family Relationships (parents, siblings, extended family, in-laws) |
| | | | | | |
| Social Relationships (friends, neighbors, colleagues, acquaintances) |
| | | | | | |
| Community relations (neighborhood, village, town, city, region) |
| | | | | | |
| Environment (pollution, access to nature, urban, suburban, rural) |
| | | | | | |
| Work (stability, income, unemployment, obligations, responsibilities) |
| | | | | | |
| Financial (monthly bills, medical debts, short-term and long-term savings) |
| | | | | | |
| Other (anything else that you can think of that causes you stress) |
| | | | | | |