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  • The FATAL 10 Self-Assessment

    Please take our short survey (average response time 5-7 minutes)

  • DEMOGRAPHICS

  • Format: (000) 000-0000.
  • RELATIONSHIP ISSUES (Check ALL that apply)*
  • Regarding my relationship as a spouse, partner, significant other - I often feel (Check ALL that apply)*

  • SUBSTANCE USE

  • I use over the counter (OTC) medications/supplements*
  • I use prescribed medications*
  • I use prescribed medications that have the potential to be addictive*
  • I use prescribed medications as prescribed*
  • I have sought treatment for a drug and/or alcohol dependency problem*

  • CUMULATIVE STRESS & TRAUMA

  • As a child I was exposed to abuse/neglect*
  • I have experienced cases on the job that I think about often*
  • I have been exposed to traumatic situations throughout my life*
  • I had an experience in which I feared serious injury or death*
  • I experience nightmares*
  • I am hypervigilant*
  • I have experienced guilt/shame*
  • I have stomach issues (acid reflux, irritable bowel syndrome, upset stomach)*
  • I often over or under eat*
  • I worry constantly*

  • SLEEP ISSUES

  • On average, I get 7-8 hours of restful sleep*

  • How many hours of restful sleep do you get on average per night * hrs.

  • I wake more than twice a night*
  • I have difficulty falling or staying asleep*
  • I have experienced: (Check ALL that apply)*

  • MENTAL HEALTH ISSUES

  • Overall, I am happy*
  • I have trouble concentrating or staying focused*
  • I have experienced low self esteem*
  • I have adequate social support*
  • I feel helpless or hopeless*
  • I have been anxious and nervous*
  • I am easily agitated*
  • I have previously experienced depression*
  • I have a family history of depression*
  • I have experienced a TBI (traumatic brain injury)*
  • I feel as though my mood and feelings are up and down*
  • My mental health affects my sleep*
  • Chronic daily stressors affect my mental health*
  • I feel as though my family would be better off without me here*
  • I have or have had thoughts of harming myself*
  • I have or have had thoughts of harming others*
  • I stopped doing things I once enjoyed*

  • MEDICAL/PHYSICAL ISSUES

  • Over the past 5 years I have experienced (Check ALL that apply):*
  • I experience pain*
  • I am on a pain management program*
  • I smoke cigarettes/vape/use marijuana or marijuana products or edibles*
  • I have experienced an injury (on or off duty) which affects my health*
  • My immunizations are up to date*
  • I had a physical in the past year*
  • I have visited the dentist in the past year for a check up*
  • I use a chiropractor*
  • Overall, I feel healthy*

  • PENDING OR NEARING RETIREMENT

  • When is the soonest you will be “eligible” to retire years months      days

  • Are you financially prepared to retire*
  • Are you emotionally prepared to retire*
  • Will retirement include continued employment*
  • My average household income is/will be dramatically reduced in retirement*
  • If retired, I find retirement to be more stressful than anticipated*
  • Should be Empty: