Emotional Wellness Questonnaire

The following questions ask about events that may be extraordinarily stressful or disturbing for almost everyone. Please circle “Yes” or “No” to report what has happened to you.

If you answer “Yes” for an event, please answer any additional questions to report: (1) whether you thought your life was in danger or you might be seriously injured; and (2) whether you were seriously injured.

If you answer “No” for an event, go on to the next event.

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Have your ever filed for bankruptcy?

If so:

Your age at the time of the event?

Have your ever been divorced? Were your parents divorced?

If so:

Your age at the time of the event?

Have you ever served in a war zone, or have you ever served in a noncombat job that exposed you to war-related casualties (for example, as a medic or on graves registration duty?)

If so:

Your age at the time of the event?
Did you think your life was in danger or you might be seriously injured?

Have you ever been in a serious car accident, or a serious accident at work or somewhere else?

If so:

Your age at the time of the event?
Did you think your life was in danger or you might be seriously injured?

Have you ever been in a major natural or technological disaster, such as a fire, tornado, hurricane, flood, earthquake, or chemical spill?

If so:

Your age at the time of the event?
Did you think your life was in danger or you might be seriously injured?

Have you ever had a life-threatening illness such as cancer, a heart attack, leukemia, AIDS, multiple sclerosis, etc.?

Have you ever had a life-threatening illness such as cancer, a heart attack, leukemia, AIDS, multiple sclerosis, etc.?

If so:

Your age at the time of the event?
Did you think your life was in danger or you might be seriously injured?

Have you ever had a life-threatening illness such as cancer, a heart attack, leukemia, AIDS, multiple sclerosis, etc.?

Before age 18, were you ever physically punished or beaten by a parent, caretaker, or teacher so that: you were very frightened; or you thought you would be injured; or you received bruises, cuts, welts, lumps or other injuries?

If so:

Your age at the time of the event?
Did you think your life was in danger or you might be seriously injured?

Have you ever had a life-threatening illness such as cancer, a heart attack, leukemia, AIDS, multiple sclerosis, etc.?

Not including any punishments or beatings you already reported inthe previous question, have you ever been attacked, beaten, or mugged byanyone, including friends, family members or strangers?

If so:

Your age at the time of the event?
Did you think your life was in danger or you might be seriously injured?

Have you ever had a life-threatening illness such as cancer, a heart attack, leukemia, AIDS, multiple sclerosis, etc.?

Has anyone ever made or pressured you into having some type of
unwanted sexual contact?

 

Note: By sexual contact we mean any contact between someone else and your private parts or between you and some else’s private parts

If so:

Your age at the time of the event?
Did you think your life was in danger or you might be seriously injured?

Have you ever been in any other situation in which you were
seriously injured, or have you ever been in any other situation in
which you feared you might be seriously injured or killed?

If so:

Your age at the time of the event?

Has a close family member or friend died violently, for example, in
a serious car crash, mugging, or attack?

If so:

Your age at the time of the event?

Have you ever witnessed a situation in which someone was seriously injured or killed, or have you ever witnessed a situation in which you feared someone would be seriously injured or killed?

Note: Do not answer “yes” for any event you already reported in previous questions.

If so:

Your age at the time of the event?