Identifier Please use the same word or number you used on the previous page.
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, rape)
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.
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.
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
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
Multiple Chemical Sensitivity
Sleep disorder *
Temporomanidibular Joint Disorder (TMJ or TMD)
Myofascial Pain Syndrome
Memory loss, dementia or other cognitive deterioration