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1. | Y | N | Do you worry about the future?
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2. | Y | N | Do you have trouble falling asleep?
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3. | Y | N | Do you reach for a cigarette, drink or tranquilizer to reduce tension?
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4. | Y | N | Do you become irritated over insignificant matters?
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5. | Y | N | Do you have less energy than you need or used to have?
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6. | Y | N | Do you have too many things to do and not enough time to do them?
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7. | Y | N | Do you have headaches or stomach problems?
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8. | Y | N | Do you feel pressured to get things done?
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9. | Y | N | Are you very concerned about being well liked and successful?
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10. | Y | N | Do you perform well enough in life to satisfy yourself?
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11. | Y | N | Do you get satisfaction from the small joys and simple pleasures in life?
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12. | Y | N | Are you able to relax and have fun?
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Score one point for "yes" answers on 1-9.
Score one point each for "no" answers on 10-12.
Prepared by Dr. Robert L. Woolfolk and Dr. Frank C. Richardson, co-authors of Stress, Sanity and Survival.
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