Please use the same word or number you used on the previous page.

Adult Experience

Please indicate yes if you experienced any of these events as an adult (age 18 and older). If you have experienced any of these events please select the age range when these occured. If any of these occured more than during one age range, please make comments in the box at the end of this list.

Death of parent

Death of sibling

Victim of violent crime
(ex. physical assault,

Involved in an abusive
relationship (ex. partner
physically abusive to you)

Very unpleasant divorce
(ex. spouse continually
threatens or stalks you)

Victimize or treated unfairly by
employer/ management/
coworkers (ex. sexual
harrassment, continually
being turned down for
promotion by boss even
when majority of staff tell
you "you should have gotten
the promotion" & you are
mostly doing the duties
required of the promotion)

Daily Health Habits

Please select from each list the statement that best describes your usual habit or routine. For chocolate, a small chocolate bar = the small 1 inch size bars commonly sold in bags of about 20  to 25 per bag. Chocolate candy comes in different forms & sizes so use your best judgement on amount of chocolate you usually eat. Ex. 3- 4 herseys kisses would add up to 1 small bar. For caffeine use, assume cup size is standard 8 oz cup. Decaffeinated soda include those marked decaffeinated & those that caffeine is not in such as Sprite or Mountain Dew. For alcohol use, assume 1 drink = 1 12 oz beer, 1 8oz mixed drink, 1 6oz glass of wine, ect.


Nicotine use:

Caffeine use:

Alcohol use:






    work days

    off days



Hobby Activities

Check all the hobbies that you have done in the past year on a regular basis. Please check only those you consider you do regularly not a one time experience. Ex. if you bungie jumped last summer but would never do again then do not check, if you deer hunt every deer hunting season then you would check the box.

quiet sedentary activities (reading, internet, watching tv, etc.)

quiet creative activities (writing, drawing, needle crafts, etc.)

musical activities (composing, singing, musical instruments, etc.)

Intellectual  activities (college classes, informational courses, etc.)

social activites (social clubs, parties, night clubs, etc.)

religious activities (Bible studies, church functions, church service, etc.)

exercise type activities (jogging, aerobic classes, riding bikes, etc.)

outdoor leisure activities (walking, fishing, flower garden, etc.)

sporting activities (hunting, deep sea fishing, sailing, etc.)

sports (football, basketball, racket ball, tennis, etc.)

volunteer activities (Red Cross, hospital, non-profit organization, etc.)

stress reduction activities (biofeedback, yoga, imagery, etc.)


Support System

Please check the items on the list of support groups you feel you can go to for emotional, spiritual, and/or financial support. These would include those who you feel listens and generally understand you most of the time. They may not necessarily pay off your bills but you feel they are there for you to encourage and comfort you when you need it.

Spouse / partner

Either of your parents

Any of your brothers or sisters

Either of your parents in-laws

Any of your brothers or sisters in-laws


Church you attend


Any organized support group(s)

People you meet on internet

Any of your children


Please check all the descriptions listed below which describes how you are or others have told you tend to be like. It is important to be honest here. Ex. if you tend to worry but don't like to show it but deep down you worry about things then you would check worry. Some of the items you check may seem to contradict each other. That's OK. People do have opposites in themselves at times.

I consider myself full of energy.

I hold my feelings in rather than show them to others.

I like to laugh or make people laugh a lot.

I feel sad or feelings easily hurt.

People ignore me or are not as friendly towards me.

I am easily frustrated or get mad easily.

I consider myself as a carefree and optimistic person.

I consider I have a strong faith or religious convictions.

I consider my nerves "bad" emotionally.

I feel tired or "burned out" ofte

Medical Conditions

Please check the conditions listed below which you have been diagnosed by a physician or specialist (ex. rheumatologist). Also if you feel you may have any of these conditions please indicate that in the appropriate bo

Chronic Fatigue Syndrome


Irritable Bowel Syndrome

Migraine Headaches


Lupus (SLE)

Multiple Chemical Sensitivity

Sleep disorder *

Temporomanidibular Joint Disorder (TMJ or TMD)

Myofascial Pain Syndrome


Memory loss, dementia or other cognitive deterioration

ncludes insomnia, sleep apnea, narcolepsy, excessive daytime sleepiness, alpha delta abnormality, restless leg syndrome, periodic limb movement.