Instructions:

Dear Robert Baker,

For each item in the following Survey, please indicate how often you experience the complaint or event described. Indicate your choice by clicking on the appropriate option.

In the example below, if over the past 30 days you have experienced difficulty in controlling your anger, then indicate how often you have experienced this kind of event.

If you do occasionally experience difficulty controlling your anger, or only sometimes in certain situations, you would click on the response option “A Little” for this item.

If you blow up all the time, or have done so quite frequently over the past 30 days, you would click on the response option “A Lot” (“All The Time” or “Frequently” are also appropriate for this item).

On the other hand, if you didn’t have difficulty controlling you anger over the past 30 days, and such an event is highly unlikely, you would click on “Not At All.”

Use the same process for all other complaint items in the Survey…there are a total of 36 items in this survey of common complaints. Please take your time and be as accurate as possible with your answers.