| Pain, both Phsyical and Emotional (X marks the spot!) ((99 questions)) |
| Answer each question with a X |
| Leave question answer blank if you haven't done what question says. |
| :: Physical :: |
| 1) Gotten into a fist fight: | x |
| 2) Been beaten up in a fist fight.: | x |
| 3) Had a black eye: | x |
| 4) Broken a bone: | x |
| 5) Broken more than one bone: | |
| 6) Sprained a bone: | x |
| 7) Sprained more than one bone: | |
| 8) Had a arm or leg dislocated.: | |
| 9) Have skinned arms: | x |
| 10) Have skinned legs: | |
| 11) Have skinned face: | |
| 12) Have skinned back: | |
| 13) Have burnt hands: | |
| 14) Have burnt arms/legs: | |
| 15) Have burnt face: | |
| 16) Have burnt back: | |
| 17) Been in a car wreck: | |
| 18) Had a nail pulled off: | |
| 19) Have had T.B.: | |
| 20) Have had Bronchitis: | x |
| 21) Have had Pink Eye: | |
| 22) Have had the Flu: | x |
| 23) Have had the Measles: | x |
| 24) Have had Chicken Pox: | x |
| 25) Have had Cow Pox: | |
| 26) Have had Cancer: | |
| 27) Have had Cancer tumor removed surgically: | |
| 28) Have had a surgery: | x |
| 29) Have given birth to a child: | |
| 30) Have fallen on or over a table: | x |
| 31) Have fallen off a roof: | |
| 32) Have slipped and fallen while walking in rain: | x |
| 33) Have slpped and fallen while roller-blading: | x |
| 34) Have slipped and fallen while ice-skating: | x |
| 35) Have slipped and fallen while taking a shower: | x |
| 36) Have had tooth punched out: | |
| 37) Have gotten injury while playing sports: | x |
| 38) Have accidently cut self with knife or other sharp object: | x |
| 39) Have been pushed or fallen out of a window: | |
| 40) Have fallen off a swing while swinging high: | |
| 41) Have been saved by lifeguard while swimming: | |
| 42) Have been shot with BB Gun: | |
| 43) Have been shot with a real gun: | |
| 44) Have been attacked by a dog or other animal: | x |
| 45) Have fallen off a horse: | |
| 46) Have walked into a door or door frame: | |
| 47) Have puked blood: | x |
| 48) Have had a body parasite: | |
| 49) Have been in airplane, train, or ship/boat crash.: | |
| 50) Have been in so much pain you thought you would die.: | |
| :: Emotional :: |
| 51) Have had close friend/family member pass away: | x |
| 52) Have had a close friend take advantage of you: | x |
| 53) Have had a family member take advantage of you: | x |
| 54) Have had a lover take advantage of you: | x |
| 55) Have witnessed a human being die: | |
| 56) Have witness an animal die: | x |
| 57) Have been dumped by a boyfriend/girlfriend: | x |
| 58) Have been teased merclessly: | x |
| 59) Have had heart broken: | x |
| 60) Have cried self to sleep: | x |
| 61) Have cried for a full day: | x |
| 62) Have considered suicide: | x |
| 63) Have attempted suicide: | x |
| 64) Have thought about burning or cutting self: | x |
| 65) Have burnt/cut self: | |
| 67) Have considered running away: | x |
| 68) Have run away: | |
| 69) Have been in shock: | x |
| 70) Have had anxiety/panic attack: | x |
| 71) Have been verbally abused to the point of hating self: | x |
| 72) Have been worried mad: | x |
| 73) Have been diagnosed depressed: | x |
| 74) Have been diagnosed bipolar: | x |
| 75) Have shut self out from others: | x |
| 76) Have considered doing something you now regret: | x |
| 77) Have done something you now regret: | x |
| 78) Have been in argument with family member/close friend: | x |
| 79) Have cried because of family member/close friend: | x |
| 80) Have been disowned by family: | |
| 81) Have disowned self from family: | |
| 82) Have considered a life of drugs: | x |
| 83) Have considered a life or crime: | |
| 84) Have given up on old dreams: | x |
| 85) Have given up on doing things that should been found fun: | x |
| 86) Have lost all will to live: | |
| 87) Look foward to death: | x |
| 88) Look foward to sleep: | x |
| 89) Been blamed for something you didn't do: | x |
| 90) Been punished for something you didn't do: | x |
| 91) Worried about something you couldn't control: | x |
| 92) Stayed up all night worrying: | x |
| 93) Stayed up all night crying: | x |
| 94) Stayed up all night cutting/burning self: | |
| 95) Stayed up all night writing in diary/journal about problems with life: | x |
| 96) Stayed up all night worrying about your 10 year future: | x |
| 97) Been extremely disappointed: | x |
| 98) Have had something you've looked foward to ruined: | x |
| 99) Have had something you planned ruined: | x |
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