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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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