Name *

First Name

Last Name

Phone

(###)

###

####

In the last month, how often have you been upset because of something that happened unexpectedly? *

Check one box only.

0 - never

1 - almost never

2 - sometimes

3 - fairly often

4 - very often

In the last month, how often have you felt that you were unable to control the important things in your life? *

Check one box only.

0 - never

1 - almost never

2 - sometimes

3 - fairly often

4 - very often

In the last month, how often have you felt nervous and stressed? *

Check one box only.

0 - never

1 - almost never

2 - sometimes

3 - fairly often

4 - very often

In the last month, how often have you felt confident about your ability to handle your personal problems? *

Check one box only.

0 - never

1 - almost never

2 - sometimes

3 - fairly often

4 - very often

In the last month, how often have you felt that things were going your way? *

Check one box only.

0 - never

1 - almost never

2 - sometimes

3 - fairly often

4 - very often

In the last month, how often have you found that you could not cope with all the things that you had to do? *

Check one box only.

0 - never

1 - almost never

2 - sometimes

3 - fairly often

4 - very often

In the last month, how often have you been able to control irritations in your life? *

Check one box only.

0 - never

1 - almost never

2 - sometimes

3 - fairly often

4 - very often

In the last month, how often have you felt that you were on top of things? *

Check one box only.

0 - never

1 - almost never

2 - sometimes

3 - fairly often

4 - very often

In the last month, how often have you been angered because of things that happened that were outside of your control? *

Check one box only.

0 - never

1 - almost never

2 - sometimes

3 - fairly often

4 - very often

In the last month, how often have you felt difficulties were piling up so high that you could not overcome them? *

Check one box only.

0 - never

1 - almost never

2 - sometimes

3 - fairly often

4 - very often