Name*

Last Name*

Have you experienced any of the following?

Parental abuse to one another:*
VerbalPhysicalNot applicable

Parental abuse to self:*

VerbalPhysicalNot applicable

Parental abuse to one siblings:*

VerbalPhysicalNot applicable

Sexual abuse:*

Familial separations:*

Mother & FatherSelfNot Applicable

Death of loved ones:

Relationship & your age at time:

Family relocations & your age at time:

School related problems:*

Victim of bullyingBerated by teachersNot Applicable

Hospitalizations*

Surgeries*

Job related problems:*

Interpersonal problems with spouse or significant others:

Motor vehicle accidents:*

Other accidents:*

Intrusive memoriesFlashbacksAvoidance Behaviors

Sleep disturbance*

Falling asleepShortened sleepInterrupted sleepExcessive sleep