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Stress & Anxiety Check-In: Understanding Your Mind & Body

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Last name

Date

Month

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Year

Please give a rating of 0-10 for each issue, 0 - not a problem at all. 10 sever issue. You can explain a little more to help your healing session.

Feeling Overwhelmed or out of control

Constant worry or fear

Irritability or mood swings

Restlessness or feeling on edge

Difficulty concentrating or making decisions

Increased sensitivity to criticism

Low self-esteem or feelings of worthless and not good enough

Depression or sadness

Panic attacks (racing heart, dizziness, shortness of breath)

Rapid heartbeat of palpitations

Muscle tension or aches and pains

Hot Flushes

Fatigue or low energy

Insomnia or trouble sleeping

Stomach issues (nausea, indigestion)

Sweating excessively

Trembling and shaking

Need to go to toilet often

Weakened immune system (often unwell)

Other...