Stress Survey Form

Thank you for taking the time to complete this survey form. South African stress levels appear to be at an all time high as a result of things like financial pressures, crime and civil unrest. My intention is to discover from South African residents what the real picture is.

Kindly note that this is an anonymous survey. The results of the survey will be published in the book I am writing on the subject.

Select your answers carefully and honestly. Remember, your anonimity is guarenteed and your responses will be very useful in the fight against high levels of stress.

Age

18 - 25

Gender

Female

Education

School Certificate

Relationship Status

Single

No. of children

26 - 35

Male

Trade

Relationship

36 - 55

56 +

Short Courses

Tertiary Degree

Post Graduate

Married

Engaged

Divorced

Separated

Enter how many sick days you have taken in the last 12 months?

What Industry do you work in?

What position do you hold?

What is the primary work that you do?

Inability to get to sleep or stay asleep

Headaches

Feeling unaccountably fatigued or exhausted

Tendency to eat and/ or drink more than usual

Tendency to smoke more than usual

Tendency to eat and/ or drink less than usual, that is, a decrease in appetite

Muscles trembling, for example, eye twitch

Feeling as though you don’t want to get up in the morning

Tendency to sweat or a feeling of your heart beating hard

4 +

Stress Survey Form for South African Residents

(For example, banking, education, health care etc.)

Indigestion

Do you live in South Africa

Yes

Enter how many years you have lived in South Africa

Select the type of area you LIVE in from the drop-down menu

Select the type of area you WORK in from the drop-down menu

Select your families INCOME PER MONTH range from the drop-down menu

Approximately how many hours do you spend on the road each day getting to and from work, or doing your work

Do you think you experience high stress levels

Yes

Select which of the following you feel cause you stress:

Physical health and safety

Finances

Personal Relationships

Crime

Work/business pressures

Civil Unrest (eg. Strikes/Protests)

Statements made by political leaders

Travelling on South African roads

Living up to the expectations of other

Uncertainty of the future

Religious beliefs and issues

Environmental issues

Below are a number of statements relating to the effects of stress on your physical health. Please indicate how often you feel the following occur by selecting one option from the drop-down menus:

Are you currently medically diagnosed with any of the following:

Anxiety Disorder

Psychosis

Sleep Disorders

Irritability

Easily become angry

Do you consume coffee? (Excluding Decaf.)

Yes

If yes, how many cups do you consume, on average, per day?

How many teaspoons of coffee do you put in a cup of coffee?

Do you consume energy drinks (eg Red Bull, Play, Monster etc)

Yes

If yes, how many cans do you consume, on average, per day?

If yes, size of can

Small

Large

Do you use energy tonics containing caffeine (eg Bioplus)

Yes

If yes, how many milliliters do you consume, on average, per day?

Do you consider yourself to have been adequately educated on how to deal with very challenging experiences?

Yes

Thank you. Now click on submit to complete the survey. You will then be redirected to this website's home page.

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