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Student Stress Survey Form
Last Name, First Name
Birthdate
Current Grade
WOULD YOU PREFER TO REMAIN ANONYMOUS?
Yes No
Gender
On a scale of 1-10, with 1 being "Not At All Stressed" and 10 being "Extremely Stressed", what has your stress level been over the past three months?*
On a scale of 1-10, with 1 being "I am completely able to function" and 10 being "I am unable to function from", how well are you able to accomplish daily tasks?*
In the past three months, has stress affected your ability to sleep?*
Yes No
How often did stress affect your ability to sleep?*

In the last three months, how has stress affected you emotionally?
Emotional Effects
Choose 1-10. 1=Not at All, 10=Extremely
New/worsening anxiety

New/worsening depression

New/worsening fear

Irritability/anger

Feeling overwhelmed

Feeling sad

Feeling restless
In the last three months, how has stress affected you socially?
Social Effects
Choose 1-10. 1=Not at All, 1-=Extremely
Isolating

Sensitive

Combative

Self-hating

Impatient

Difficulty interacting/communicating
In the last three months, have the following areas caused you stress?
Social Effects
Choose 1-10. 1=Not at All, 1=Extremely
Academics

Extracurricular Clubs/Groups

Family

Finances

Friends

Health

Sports

Work
What do you usually turn to when you need to relax? (choose all that apply)*
Art/music Computer games Eating Exercise Spending time outdoors Spending time with firends, loved ones, pets Sleep Social media Substances (alcohol, drugs, tobacco) Other
What do you wish that others knew about the stress that students deal with today?*
What can parents/school authorities do to help decrease the student stress level?*
Please share any other thoughts/comments.

Physical Effects	Choose 1-10. 1=Not at All, 10=Extremely
Change in sleeping habits, ability to rest and relax
Change in eating habits
Change in grooming habits
Change in energy level
Difficulty communicating
Difficulty concentrating
Feeling the need to start using/increase caffeine, tobacco, alcohol, drugs
Accident prone
Mood swings
Increased cases of illness

Social Effects	Choose 1-10. 1=Not at All, 1-=Extremely
Isolating
Sensitive
Combative
Self-hating
Impatient
Difficulty interacting/communicating

Social Effects	Choose 1-10. 1=Not at All, 1=Extremely
Academics
Extracurricular Clubs/Groups
Family
Finances
Friends
Health
Sports
Work

Student Stress Survey Form