Life Events, Concerns, and Interests
Name
First Name
Last Name
Concerns or Interests
Which do you feel apply to you?
Rows
Strongly
Somewhat
Rarely
Never
Stress/Tension
Memory
Concentration
Addictions
Compulsive Behaviors
Anxiety
Depression
Low Self-Esteem
Artist’s Block
Panic Attacks
Insomnia/Sleep Problems
Weight Issues
Guilt Feelings
Lying/Cheating
Relationships
Sexuality
Shyness
Headaches
Work Problems
Residual/Chronic Pain
Surgical/Dental Anxiety
Communication
Health
Emotional Trauma
Motivation
Smoking Cessation
Other
If other, details?
Life Event Ratings
Which events have you experienced in the past 12 months?
Rows
Repeatedly
Once
Not at All
Death of Spouse or Partner
Divorce
Marital Separation
Death of a close family member
Personal Injury or Illness
Marriage
Loss of job
Marital Reconciliation
Retirement
Change in health of family member
Pregnancy
Sexual Difficulties
Gain of new family member
Change in financial state
Death of a close friend
Change to different line of work
Change in responsibilities at work
Outstanding personal achievement
Spouse begins or stops work
Change in living conditions/arrangements
Change in recreational/social activities
Change in eating habits
Vacation
Change in spiritual practices
Return to school/academics
Relocation
Other
If other, details?
Any fears or phobias?
Any additional information you feel is relevant and would be of benefit to share?
Email
example@example.com
Send
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