Name: *
Email: *
City: *
When you have been under stress for a long time you will start to get certain biofeedback signals from your body. This test will help you determine to what degree you are having these signals. Upon completing this test you will receive some feedback on your results and a bit of advice if needed.

Can you please tell me a little bit about your situation? Answering this question is optional but it would give me more context to help you.
{"type":"textarea","name":"somethingaboutyoursituation","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":250,"placeholder":""}

How would you rate your energy level over the last weeks? 
{"type":"radio","name":"energyLevelnl","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please indicate your overall energy level.","options":"1 - I have been feeling very lackluster\n2\n3 \n4 - Normal\n5 \n6\n7- I felt full of energy"}

How would you rate your average stresslevel over the last few weeks?
{"type":"radio","name":"Stresslevel","width":70,"value":"","size":"Normal","validation":"C1","validationMessage":"Please fill in this item.","options":"1 - Everything goes smoothly and without to much effort\n2\n3\n4\n5 \n6\n7 - I feel anxious pretty much all the time"}


Sleep is vital for good mental and emotional health. During sleep, your mind gets the change to offload and process all the stimuli of the day. Furthermore, sleep is crucial in physical recovery as well. When you are unable to sleep well for a prolonged period of time, this can impair your emotional and mental fitness and become problematic.

To what degree does the below apply to you?

On average I have Hours345678910>10{"type":"select","name":"numberofhourssleep","width":20,"value":"","size":"Small","validation":"N1","validationMessage":"Please fill in this item.","options":"Hours\n3\n4\n5\n6\n7\n8\n9\n10\n>10"}
 a day of sleep

How easy do you fall asleep normally?
{"type":"radio","name":"sleeponsetnl","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please indicate the quality of your sleep.","options":"Usually within 10 minutes\nBetween 15 and 30 minutes\nBetween 30 and 45 minutes\nIt usually takes me more than 45 minutes to fall asleep"}

How would you score your average sleep?
{"type":"radio","name":"sleepQuality","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please indicate the quality of your sleep.","options":"1- Very bad\n2 -Bad\n3- Not bad but could be a lot better\n4- Good\n5 -Great!"}

How often do you awake during the night?
{"type":"radio","name":"sleepwakkerworden","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please indicate the quality of your sleep.","options":"I seldom wake up during the night\nMaybe once a night\nAt least 1 or 2 times a night\nMore than 3 times a night"}


Your digestive system is linked to your autonomous nervous system. Your nervous system consists of two modes, your parasympathetic nervous system which is also called the rest-and-digest system, and the sympathetic nervous system which you might know as fight-or-flight. Normally you will alternate between these two states during the day but if you are chronically stressed or overload you get stuck in the fight-or-flight mode. This means that your digestive system gets less of a priority and in turn, can cause digestive issues or loss of appetite. 


How has your appetite been lately?

{"type":"radio","name":"Appetite","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please fill in this item.","options":"1- I eat a lot less than normal and don't have much of an appetite\n2\n3 - My appetite is pretty much the same as always\n4 - \n5 - I eat way more than normal."}

Select what applies to you
{"type":"checkbox","name":"eatinhhabits","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","options":"My eating habits have not changed\nI have noticed that I crave more sweets lately\nMy alcohol consumption has increased substantially\nI have gained weight or lost weight some substantial weight lately\nlately, I have started to suffer some allergies and/or skin rashes or irritation\nIt seems that I react differently to certain foods lately\nNone of the above"}


Emotional and mental

No doubt, long term stress has a substantial impact on your emotional and mental wellbeing. You might become more forgetful, irritable or have a general feeling of depression or hopelessness.
When you have been under emotional or mental stress for a time you might start to feel like the normal everyday stimuli are too much. Your mind has been overstimulated either from within or without and is less able to compute everything that is happening causing you to become more irritable at times. 

Read the below statements and select those which apply to you

{"type":"checkbox","name":"paniekgevoel","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","options":"I have a far shorter fuse than usual and tend to lose my temper more quickly\nI notice that I find it more difficult to not overreact in certain situations and need to really try not to overreact\nWhen I am around a lot of people or a lot of sounds I tend to get anxious and get the urge to extract myself from the situation\nLately, I noticed that I tend to retreat myself more and tend to avoid business places\nRecently, I start to experience social events and engagements more and more obligations and I feel dread to even attend.\nNone of the above"}

When your mind has been strained for a longer period of time you might become mentally exhausted which can cause your subconscious mind to interpret situations as a thread. This, in turn, can translate into feeling fearful or even panic attacks. To what degree do you recognize the below statements?

{"type":"checkbox","name":"angstiggevoel","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","options":"I have had multiple instances in which I felt what could be described as a panic attack\nI have noticed that particular situations, emotions and/or thoughts trigger a very anxious feeling\nI have noticed somethings now make me anxious, nervous or insecure which didn't use to."}

When someone is heading for a burn-out there are often persistent repeating thoughts at play. Do you recognize this?
{"type":"radio","name":"repeatingThoughts","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","options":"Yes! I keep having the same repeating thoughts over and over again. I am continuously over-analyzing and worrying\nYes, I do occasionally have repeating thoughts but I do not experience them as worrying or troublesome thoughts\nN0, I don't recognize myself in this."}

Stress also has a negative influence on some cognitive functions. For example, tasks you would normally do without much of an effort now require much more focus or you are more forgetful than you used to be. Does this sound familiar?
{"type":"radio","name":"cognitiveimpairment","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please fill in this item.","options":"Yes, I have noticed that I am more forgetful than normal and that mundane tasks now require much more focus and effort\nNo, I haven't noticed being more forgetful but I do notice that I have to focus more on the simple tasks\nNo, I don't recognize this at all."}


Prolonged stress will cause certain physical reactions which I'd like to call biofeedback signals. Please look at the below symptoms and see how they relate to you.

Knot in my stomach
{"type":"radio","name":"physicalsymptons","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please fill in this item.","options":"1 - Never\n2 - Rarely\n3 - Regularly\n4 - All the time"}

A stiff or painfull neck
{"type":"radio","name":"physicalsymptons2","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please fill in this item.","options":"1 - Never\n2 - Rarely\n3 - Regularly\n4 - All the time"}

Do you experience back pain which you didn't previously?
{"type":"radio","name":"backpain","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please fill in this item.","options":"Yes\nNo"}

Do you experience constant muscle ache?
{"type":"radio","name":"lichamelijkeklachten4","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please fill in this item.","options":"Yes\nNo"}

{"type":"radio","name":"physicalsymptons3","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please fill in this item.","options":"1 - Never\n2 - Rarely\n3 - Regularly\n4 - All the time"}

{"type":"radio","name":"physicalsymptons4","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please fill in this item.","options":"1 - Never\n2 - Rarely\n3 - Regularly\n4 - All the time"}

You are done! That where all the questions. Thank you for your honest answers and remember that even if you are feeling lost there is always a way out. I will take a look at your results and come back with some feedback.

If you have any questions, don't hesitate to send me a message.