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Life Event Past 12 Months |
Yes
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No
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describe how you are coping
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1. |
Became disabled or incapacitated. |
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2. |
Loss of sense of self. |
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3. |
Loss of independence. |
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4. |
Loss of identity and stature. |
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5. |
Dependent on others for basic subsistence. |
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6. |
Dependent on others for personal care and maintenance. |
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7. |
Loss of self-determination and self-sufficiency. |
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8. |
Loss of personal mobility. |
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9. |
Loss of previous capacities and capabilities. |
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10. |
Sexual problems |
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11. |
Infidelity. |
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12. |
Divorce or separation. |
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13. |
Change in closeness with spouse, lover, partner. |
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14. |
Reconciled with partner, lover. |
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15. |
Ongoing conflict with present spouse, lover, etc. |
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16. |
Conflict with parents, siblings and family members. |
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17. |
Problems with former spouse, lover, partner. |
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18. |
Social isolation. |
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19. |
Change in social activities |
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20. |
Family turmoil |
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21. |
Became engaged. |
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22. |
Married or began a live-in relationship. |
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23. |
Problems with co-workers. |
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24. |
Work interfered with family life. |
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25. |
You or partner fired. |
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26. |
Major change in conditions of work. |
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27. |
Death of a spouse, lover, or other family member |
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28. |
Death of a child (including miscarriage or stillbirth). |
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29. |
Pregnancy. |
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30. |
Became a parent. |
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31. |
Child or family member left home. |
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32. |
Child returned home with a child, etc. |
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33. |
Change in marital status of your children or parents. |
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34. |
Gained new, live-in, family member. |
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35. |
Changed residence. |
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36. |
Landlord problems. |
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37. |
Mortgage or loan foreclosure. |
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38. |
Became homeless |
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39. |
Moved to new town. |
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40. |
Loss of regular transportation. |
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41. |
Began adolescence. |
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42. |
Graduated high school or college |
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43. |
Embarked on new career |
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44. |
Began menopause. |
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45. |
Other major life change. |
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46. |
Long-term or life-threatening illness or injury. |
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47. |
Major change in health or behavior of family or friend. |
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48. |
Long-term illness, injury or disability of household member. |
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49. |
Death of family or household member. |
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50. |
Major decision regarding your immediate future. |
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51. |
Major personal achievement. |
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52. |
Change in your personal habits, lifestyle, dress, hobbies. |
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53. |
Change in your religious or political beliefs. |
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54. |
Loss or damage to personal property |
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55. |
Vacation. |
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56. |
Trip, not a vacation. |
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57. |
Christmas / Thanksgiving, or other major holiday |
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58. |
Change in family get-togethers. |
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59. |
Change in your social activities. |
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60. |
Made a new friend. |
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61. |
Broken up with a friend due to conflict. |
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62. |
Lost friend any other reason, death, moving. |
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63. |
Major change in finances. |
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64. |
New purchase, car, etc. |
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65. |
New mortgage loan. |
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66. |
Credit rating difficulties. |
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67. |
Violent crime victim |
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68. |
Physical abuse by partner, parent, caregiver, etc. |
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69. |
Emotional abuse. |
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70. |
Injured in car or other accident. |
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71. |
Involved in injury claim or law suit. |
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72. |
Law suit against you. |
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73. |
Jailed due to legal trouble. |
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74. |
Victim of natural disaster. |
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75. |
Change in sleep habits. |
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76. |
Change in diet and appetite |
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77. |
Developed thinking and learning disabilities. |
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78. |
Developed problems with emotional control. |
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79. |
Sudden decline in grades |
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80. |
Asked to withdraw from school, or dropped out of school. |
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81. |
Conflict with school officials. |
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82. |
Conflict with classmates |
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83. |
Change in child care. |
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84. |
Parenting conflicts. |
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85. |
Conflicts with children. |
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86. |
Single parenting. |
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87. |
Custody battles. |
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88. |
Child abuse issues. |
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89. |
Learning disabled child. |
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90. |
Emotionally fragile child. |
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Total events "YES" responses in past 12 months |
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