Hello,

Welcome back to school. We’ve been through a lot since the pandemic started. We know that
education can be very stressful especially during this difficult time. We ask that you honestly and
sincerely answer the following questions for us to capture feedback and assess your mental health
status. This way, we would be able to find ways to help you adapt into the new normal and improve
your academic experience.

Read each question carefully and reflect. Thank you for your cooperation.

NAME: ______________________________________ GENDER: ______

GRADE: _____ SECTION: _________________ ADVISER: ___________________

1. If you are to rate your stress level during this academic year, how would you rate it from 1 – 5, 5
being high level of stress.

1 2 3 4 5

2. What are your common causes of stress? Check all that applies.
___ Studies issues ___ Health issues
___ Financial issues ___ Other issues:
___ Family issues Please specify: ___________________________
___ Friends issues
___ Relationship issues

3. From the causes of stress you selected above, what are the physical sensations and feelings you
encounter when you are stressed. Please describe below.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

4. What are the common BEHAVIORAL effects of stress you’ve noticed at yourself? (Check all that
applies).
___ Irritability, outburst of anger ___ Decreased efficiency and effectiveness
___ Change in eating habits ___ Inability to rest
___ Change in sleeping pattern ___ Lost of interest
___ Periods of crying ___ Difficulty communicating
___ Absenteeism ___ Others (Please specify)
________________________________
5. What are the common EMOTIONAL effects of stress you’ve noticed at yourself? (Check all that
applies).
___ Anxiety or fear ___ Feeling euphoric
___ Irritability or anger ___ Guilt feelings
___ Sadness, moodiness, helpless, hopeless ___ Absenteeism
___ Feeling lonely, alone, abandoned, ___ Feeling unappreciated
and isolated ___ None
___ Distressing and/or vivid dreams ___ Others (please specify)
or nightmare _____________________________

6. What are the usual PHYSICAL effects of stress you’ve noticed at yourself? (Check all that
applies).
___ increased heart rate ___ easily startled
___ increased blood pressure ___ menstrual cycle changes
___ upset stomach, nausea, diarrhea ___ flare up of allergies, asthma
___ increased/decreased appetite ___ decreased resistance to flu, colds,
infections
___ sweating/ chills ___ hair loss
___ feeling uncoordinated ___ headaches
___ muscle pain ___ tremors
___ others (please specify) ___________________________________________

7. What are the usual COGNITIVE effects of stress you’ve noticed at yourself? (Check all that
applies).
___ forgetfulness ___ difficulty concentrating
___ disorientation ___ limited attention span
___ confusion ___ difficulty calculating and making decisions

___ slowness in thinking, analyzing, ___ None of the above

And comprehending ___ Others (Please specify)

______________________________

8. What are the usual SOCIAL effects of stress you’ve noticed at yourself? (Check all that applies).
___ withdrawing or isolating from people ___ intolerance of group process/ activities
___ difficulty listening ___ difficulty engaging with other people
___ impatient ___ difficulty in accepting or asking for help
___ disrespectful of others ___ difficulty in sharing ideas
___ blaming ___ None
___ others (please specify) ______________________________________________________

9. How do you relieve stress? Name at least three activities you do.
 ______________________________________________________________
______________________________________________________________
______________________________________________________________

10. What are the most pressing stress factors in your academic context? Check all that applies.
___ Module workload ___ Relationship with teachers/adviser
___ Grades ___ Relationship with classmates
___ Financial (for mobile data, living costs, etc) ___ Transportation
___ Others (please specify)
______________________________________________________________

11. What is something that the school could do to help lower your stress?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_______________________________________________.