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Please provide the following:
Please fill in all required fields so your form is properly processed.
First Name: * required
Last Name: * required
E-Mail: * required
Please indicate each and every one of the following events that happened to you DURING THE PAST 12 MONTHS:
(NOTE: Death of a spouse is valued at 100 and divorce at 73 - so you can evaluate the relative stress you are experiencing by your total points displayed after you click SUBMIT).
Death of a spouse (husband or wife).
Sentenced to jail
Death of a close family member (mother, father, sister, brother, child).
Personal injury or illness
Got married
Fired from job
Got back together with husband or wife (reconciliation).
Retired
Change in health of a family member (got sick, got worse, or got better)
Pregnancy (self, wife, girl friend)
Sex problems
Gain a new family member (child, brother or sister)
Business readjustment (going out of business, starting or changing business)
Change in financial state (went broke, or made more money than usual)
Death of close friend
Change to a different line of work
Change in number of arguments with spouse (wife or husband) either more arguments or less
Mortgage of more than $10,000
Foreclosure of morgage or loan (collection or loan called in)
Change in level of responsibility at work
Son or daughter left home
Trouble with in-laws (with wife's or husband's parents or family)
Outstanding personal accomplishment (you did exceptionally well at something)
Wife began or stopped working outside home
Begin or end school
Change in living conditions (better or worse home; more or less money to spend)
Change of personal habits (changed self or your behavior)
Trouble with boss
Change in work hours or conditions (more or fewer breaks, benefits changed)
Moved your place of residence
Changed schools
Changed what you do with your spare time
Changed your church activities
Changed social activities (the things you do with your friends)
Mortgage or loan less than $10,000
Change in sleeping habits
Change in number of family get-togethers
Vacation
Christmas
Minor violations of the law (traffic tickets, etc)

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