Make Stress A Thing Of The Past
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:*
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