When you were a child, before the age of 10, did you experience any of the following?
Have you ever been diagnosed or suffered any of these conditions / symptoms? Please mark which one.

In the past months, how much were you bothered by:

Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem carefully and then circle one of the numbers to the right that best match your experience.

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