Medical Questionnaire – Stress Assessment Last name(Required) First name(Required) Date of Birth(Required) DD dash MM dash YYYY Childhood Trauma Assessment and Perceived Stress ScaleCheck what applies to you before your 18th birthday. Has a parent or other adult in the household often, or very often, sworn, insulted, belittled, humiliated, or acted in a way that made you fear being physically harmed? Has a parent or other adult in the household often or very often: pushed, grabbed, slapped, or thrown something at you or ever hit you so hard that you have marks or hurt yourself? Has an adult or someone at least 5 years older than you ever touched or fondled or caused to be touched in a sexual way or attempted to have oral, or vaginal sex with you? Have you often or very often felt that one or more people in your family didn’t like you or thought you were important or special? Or that your family wasn’t looking out for each other, feeling close to each other, or supporting each other? Have you often or very often felt that you didn’t have enough to eat, that you had to wear dirty clothes, and that you had no one to protect you? Or that your parents were too drunk or too drugged to take care of you or take you to the doctor if you needed to? Were your parents separated or divorced? Has your mother or mother-in-law been pushed, grabbed, slapped, or thrown at her often? sometimes, often or very often kicked, bitten, hit with a fist or with something hard; Or has she ever been repeatedly beaten for at least a few minutes or threatened with a gun or knife? Have you lived with someone who had problems with alcohol or drug addiction, or who used street drugs? Was a member of the household depressed or mentally ill, or attempted suicide? Has anyone in the household been incarcerated? For each question, select the frequency that is appropriate for you.Over the past month, how many times have you felt like you can't control the important things in your life? Never Hardly ever Sometimes Quite often Very often In the past month, how many times have you been upset because of an unexpected event? Never Hardly ever Sometimes Quite often Very often In the past month, how many times have you felt confident in your ability to deal with your personal problems? Never Hardly ever Sometimes Quite often Very often In the past month, how many times have you felt like things were going your way? Never Hardly ever Sometimes Quite often Very often In the past month, how many times have you felt unable to cope with all the things you had to do? Never Hardly ever Sometimes Quite often Very often In the past month, how many times have you felt nervous and stressed? Never Hardly ever Sometimes Quite often Very often In the past month, how many times have you been able to control irritation in your life? Never Hardly ever Sometimes Quite often Very often Over the past month, how many times have you felt like you were in control? Never Hardly ever Sometimes Quite often Very often In the past month, how many times have you gotten angry because of events beyond your control? Never Hardly ever Sometimes Quite often Very often Au cours du mois dernier, combien de fois vous êtes-vous mis en colère à cause d'événements indépendants de votre volonté ? Never Hardly ever Sometimes Quite often Very often CAPTCHA
