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1.Do you feel anxious or nervous when you are around your partner?
No
Sometimes
Regularly

2. Do you watch what you are doing in order to avoid making your partner angry or upset?
No
Sometimes
Regularly

3. Do you feel obligated or coerced into having sex with your partner?
No
Sometimes
Regularly

4. Are you afraid of voicing a different opinion than your partner?
No
Sometimes
Regularly

5. Does your partner criticize you or embarrass you in front of others?
No
Sometimes
Regularly

6. Does your partner check up on what you have been doing, and not believe your answers?
No
Sometimes
Often

7. Is your partner jealous, such as accusng you of having affairs?
No
Sometimes
Often

8. Does your partner tell you that he or she will stop beating you when you start behaving yourself?
No
Yes

9. Have you stopped seeing your friends or family because of your partner's behavior?
No
Yes

10. Does your partner's behavior make you feel as if you are wrong?
No
Sometimes
Regularly

11. Does your partner threaten to harm you?
No
Sometimes
Regularly

12. Do you try to please your partner rather than yourself in order to avoid being hurt?
No
Sometimes
Regularly

13. Does your partner keep you from going out or doing things that you want to do?
No
Sometimes
Regularly

14. Do you feel that nothing you do is ever good enough for your partner?
No
Sometimes
Regularly

15. Does your partner say that if you try to leave him or her, you will never see your children again?
No
Yes
Not applicable

16. Does your partner say that if you try to leave, he or she will kill himself or herself or you?
No
Sometimes
Regularly

17. Is there always an excuse for your partner's behavior? ("The alcohol or drugs made me do it! My job is too stressful! If dinner was on time I wouldn't have hit you! I was just joking!")
No
Sometimes
Regularly

18. Do you lie to your family, friends and doctor about your bruises, cuts and scratches?
No
Yes
Not applicable

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I am a year old /

1. I do things slowly.







2. My future seems hopeless.







3. It is hard for me to concentrate on reading.







4. The pleasure and joy has gone out of my life.







5. I have difficulty making decisions.







6. I have lost interest in aspects of life that used to be important to me.







7. I feel sad, blue, and unhappy.







8. I am agitated and keep moving around.







9. I feel fatigued.






 

Alcohol Use Disorders Identification Test (AUDIT)

The following questions are about your behaviors in the past year. A score of 8 or more is suggestive of at-risk drinking. Patients who score positive on the AUDIT should be assessed for potential alcohol-related problems.

 

1. How often do you have a drink containing alcohol?




2. How many drinks containing alcohol do you have on a typical day when you are drinking?







3. How often do you have six or more drinks on one occasion?






4. How often during the last year have you found that you were unable to stop drinking once you had started?






5. How often during the last year have you failed to do what was normally expected from you because of drinking?






6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?






7. How often during the last year have you had a feeling of guilt or remorse after drinking?






8. How often during the last year have you been unable to remember what happened the night before because you had been drinking?






9. Have you or someone else been injured as the result of your drinking?






10. Has a relative, friend, or a health worker been concerned about your drinking or suggested you cut down?






 
*** Remember: A score of 8 or more is suggestive of at-risk drinking. Patients who score positive on the AUDIT should be assessed for potential alcohol-related problems.
AUDIT Reference: Babor TF, de la Fuente JR, Saunders J, Grant M. AUDIT: The Alcohol use Disorders Identification Tests: Guidelines for use in Primary health Care. Geneva, Switzerland: World Health Organization, 1992.

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Think back about how you've felt over the past month. Please choose how often you've experienced each of the following anxiety symptoms during that time:

  Usually Often Sometimes Rarely Never
Pounding heart
Sweating
Trembling or shaking
Shortness of breath
Afraid or scared
Chest pain or discomfort
  Usually Often Sometimes Rarely Never
Nausea or abdominal distress
Feeling dizzy or unsteady
Fear of losing control or going crazy
Numbness or tingling sensations
chills or hot flashes
Fear of dying
  Usually Often Sometimes Rarely Never
Constant or persistent worry
Feeling of choking
Unable to relax
Feeling of being unreal
Nervous
Feeling shaky or wobbly
  Usually Often Sometimes Rarely Never
Irritable or difficulty sleeping
Trembling hands
Avoid situations because of anxiety
Feeling lightheaded or faint