"*" indicates required fields Step 1 of 7 14% RelationshipsInstructions: Please respond to each question or statement by marking one box per row. In the past month, please describe how often.Relationships*NeverRarelySometimesOftenAlwaysI have someone who understands my problemsI have someone who will listen to me when I need to talkI feel there are people I can talk to if I am upsetI have someone to talk with when I have a bad dayI have someone I trust to talk with about my problemsI have someone I trust to talk with about my feelingsI can get helpful advice from others when dealing with a problemI have someone to turn to for suggestions about how to deal with a problem TraumaInstructions: Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem carefully and then select one of the options to the right to indicate how much you have been bothered by that problem in the past month. Trauma*Not at AllA Little BitModeratelyQuite a BitExtremelySuddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?Feeing distant or cut off from other people?Irritable behavior, angry outbursts, or acting aggressively? Mood/DepressionInstructions: Over the last SEVEN (7) DAYS, how often have you been bothered by any of the following problems. Check the option that best describes the frequency of the problem.Mood*Not at AllSeveral DaysMore Than Half the DaysNearly Every DayLittle interest or pleasure in doing thingsFeeling down, depressed, or hopelessTrouble falling or staying asleep, or sleeping too muchFeeling tired or having little energyPoor appetite or overeatingFeeling bad about yourself – or that you are a failure or have let your family downTrouble concentrating on things, such as reading the newspaper or watching televisionMoving or speaking so slowly that other people could have notice? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usualThoughts that you would be better off dead or of hurting yourself in some way AnxietyInstructions: Over the last SEVEN (7) DAYS, how often have you been bothered by any of the following problems. Check the option that best describes the frequency of the problem.Anxiety*NeverRarelySometimesOftenAlwaysI felt fearfulI felt anxiousI felt worriedI found it hard to focus on anything other than my anxietyI felt nervousI felt uneasyI felt tense AlcoholInstructions: Over the last SEVEN (7) DAYS, how often have you been bothered by any of the following problems. Check the option that best describes the frequency of the problem.Alcohol 1*NeverMonthly or Less2-4 Times a Month2-3 Times Per Week4 or More Times a WeekHow often do you have a drink containing alcohol?Alcohol 2*Don’t Drink, or 1 to 23 to 45 to 67 to 910 or MoreHow many standard drinks containing alcohol do you have on a typical day?Alcohol 3*NeverLess Than MonthlyMonthlyWeeklyDaily or Almost DailyHow often do you have six or more drinks on one occasion? Substance Use/AbuseInstructions: Over the last SEVEN (7) DAYS, how often have you been bothered by any of the following problems. Check the number that best describes the frequency of the problem (Drugs include opioids, stimulants, marijuana, inhalants). Substance Use/Abuse*NoYesHave you used drugs other than those required for medical reasons?Do you use more than one drug at a time?Are you always able to stop using drugs when you want to?Have you had “blackouts” or “flashbacks” as a result of drug use?Do you ever feel bad or guilty about your drug use?Does your spouse (or parents) ever complain about your involvement with drugs?Have you neglected your family because of your use of drugs?Have you engaged in illegal activities in order to obtain drugs?Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)? Behavioral AddictionsInstructions: In the past year, has your involvement in (gambling, video games, sex, work, food, shopping, exercise, smartphone usage, or some other potentially addictive behavior) caused you to…Behavioral Addictions*NoYesEngage in the behavior(s) longer or more frequently than you intended?Make an attempt to cut down, control, or stop the behavior(s)?Feel guilty about the behavior(s)?Engage in more of the behavior(s) to get the same level of excitement or pleasure?Feel annoyed by people complaining about your behavior(s)?Lie about your behavior(s)?CAPTCHA
