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What is your gender?
 
Male
 
Female
 
Age
 

 
 
What is your stress level?
 
Low
 
Medium
 
High
 
 
What is your main cause of stress?
 
Family
 
School
 
Extra Curricular Activity
 
Other
 
 
 
How do you reduce stress?
 
Music
 
Hobby
 
Friends/Parents
 
Food/Snacks
 
Other
 
 
 
Is stress affecting your sleep?
 
Yes
 
No

 
 
How many hours of sleep do you often receive? 
 
8 hours or more
 
7 hours
 
6 hours
 
5 hours or less
 
 
Are you easily irritated? 
 
Yes
 
No
 
 
How much junk food do you eat?
 
I don't eat junk food
 
a small amount
 
a medium amount
 
a large amount
 
I usually eat junk food as a late night snack
 
 
Do you often find yourself paranoid?
 
Yes
 
No
 
Sometimes
 
 
Do you often forget things?
 
Yes
 
No
 
Somewhat
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