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Listed below are a number of events that sometimes bring about change in the lives of those who experience them and which necessitate
social readjustment. Please check those events which you have experienced in the recent past and indicate the time period during which you
have experienced each event. Be sure that all check marks are directly across from the items they correspond to.
Also, for each item checked below, please indicate the extent to which you viewed the event as having either a positive or negative impact
on your life at the time the event occurred. That is, indicate the type and extent of impact that the event had. A rating of -3 would indicate
an extremely negative impact. A rating of 0 suggests no impact either positive or negative. A rating of +3 would indicate an extremely
positive impact.
Event happen in past year?
If Yes…
NO
YES
0 to 6
months
7
months
to 1
year
If Yes…
Extremely
Negative
Moderately
negative
Somewhat
negative
No Impact
Slightly
positive
Moderately
positive
Extremely
Positive
Part 1
1.
Marriage
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
2.
Detention in jail or comparable
institution
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
3.
Death of spouse
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
4.
Major change in sleeping habits
(much more or much less sleep) q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
5.
Death of a close family
member:
a. mother
b. father
Event happen in past year?
c. brother
d. sister
e. grandmother
f. grandfather
g. other
If Yes…
NO
YES
0 to 6
months
7
months
to 1
year
q 2
q 1
q 1
q 2
q 2
q 1
q 1
q 2
q 1
q 2
If Yes…
Extremely
Negative
Moderately
negative
Somewhat
negative
No Impact
Slightly
positive
Moderately
positive
Extremely
Positive
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
(specify:_____________)
6.
7.
Major change in eating habits
(much more or much less food
intake)
Foreclosure on mortgage or
loan
8.
Death of close friend
9.
Outstanding personal
achievement
10. Minor law violations (traffic
tickets, disturbing the peace,
etc.)
Event happen in past year?
11. Male: Wife/ girlfriend’s
pregnancy
12. Female: Pregnancy
13. Changed work situation
(different work responsibility,
major change in working
conditions, working hours,
etc.)
14. New job
If Yes…
If Yes…
NO
YES
0 to 6
months
7
months
to 1
year
q 2
q 1
q 1
q 2
q -3
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 2
q 1
q 1
q 2
q -3
q -2
q 2
q 1
q 1
q 2
q -3
q 2
q 1
q 1
q 2
q 2
q 1
q 1
q 2
q 1
q 2
q 2
Extremely
Negative
Moderately
negative
Somewhat
negative
No Impact
Slightly
positive
Moderately
positive
Extremely
Positive
q -2
q -1
q 0
q +1
q +2
q +3
q +1
q +2
q +3
q 0
q +1
q +2
q +3
q -1
q 0
q +1
q +2
q +3
q -2
q -1
q 0
q +1
q +2
q +3
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
15. Serious illness or injury of
close family member:
a. father
b. mother
c. sister
d. brother
e. grandfather
f. grandmother
Event happen in past year?
g. spouse
h. other
If Yes…
If Yes…
NO
YES
0 to 6
months
7
months
to 1
year
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 2
q 1
q 1
q 2
q -3
q -2
q 2
q 1
q 1
q 2
q -3
q 2
q 1
q 1
q 2
q 2
q 1
q 1
q 2
q 1
q 2
q 2
Extremely
Negative
Moderately
negative
Somewhat
negative
Slightly
positive
Moderately
positive
Extremely
Positive
q +1
q +2
q +3
q 0
q +1
q +2
q +3
q -1
q 0
q +1
q +2
q +3
q -2
q -1
q 0
q +1
q +2
q +3
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
No Impact
(specify:____________)
16. Sexual difficulties
17. Trouble with employer (in
danger of losing job, being
suspended, demoted, etc.)
18. Trouble with in- laws
19. Major change in financial
status (a lot better off or a lot
worse off)
20. Major change in closeness of
family members (increased or
decreased closeness)
21. Gaining a new family member
(through birth, adoption,
family member moving in,
etc.)
22. Change of residence
Event happen in past year?
23. Marital separation from mate
(due to conflict)
24. Major change in church
activities (increased or
decreased attendance)
25. Marital reconciliation with
mate
26. Major change in number of
arguments with spouse (a lot
more or a lot less arguments)
27. Married male: Change in
wife’s work outside the home
(beginning work, ceasing
work, changing to a new job,
etc.)
28. Married female: Change in
husband’s work (loss of job,
beginning new job, retirement,
etc.)
29. Major change in usual type
and/or amount of recreation
If Yes…
If Yes…
NO
YES
0 to 6
months
7
months
to 1
year
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 2
q 1
q 1
q 2
q -3
q -2
q 2
q 1
q 1
q 2
q -3
q -2
Extremely
Negative
Moderately
negative
Somewhat
negative
Slightly
positive
Moderately
positive
Extremely
Positive
q +1
q +2
q +3
q 0
q +1
q +2
q +3
q 0
q +1
q +2
q +3
q +1
q +2
q +3
q 0
q +1
q +2
q +3
q -1
q 0
q +1
q +2
q +3
q -1
q 0
q +1
q +2
q +3
No Impact
Event happen in past year?
30. Borrowing more than $10,000
(buying home, business, etc.)
31. Borrowing less than $10,000
(buying car, TV, getting
school loan, etc.)
32. Being fired from job
33. Male: Wife/ girlfriend having
abortion
34. Female: Having abortion
35. Major personal illness or
injury
36. Major change in social
activities, e.g., parties, movies,
visiting (increased or
decreased participation)
37. Major change in living
conditions of family (building
new home, remodeling,
deterioration of home,
neighborhood, etc.)
If Yes…
NO
YES
0 to 6
months
7
months
to 1
year
q 2
q 1
q 1
q 2
q 2
q 1
q 1
q 2
q 1
q 2
If Yes…
Extremely
Negative
Moderately
negative
Somewhat
negative
No Impact
Slightly
positive
Moderately
positive
Extremely
Positive
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
Event happen in past year?
If Yes…
NO
YES
0 to 6
months
7
months
to 1
year
q 2
q 1
q 1
q 2
q 2
q 1
q 1
q 2
q 1
q 2
If Yes…
Moderately
negative
Somewhat
negative
No Impact
Slightly
positive
Moderately
positive
Extremely
Positive
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
45. Breaking up with boyfriend /
girlfriend
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
46. Leaving home for the first
time
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
47. Reconciliation with boyfriend/
girlfriend
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
38. Divorce
39. Serious injury or illness of
close friend
40. Retirement from work
41. Son or daughter leaving home
(due to marriage, college, etc.)
42. Ending of formal schooling
43. Separation from spouse (due
to work, travel, etc.)
44. Engagement
Other recent experiences that have had an impact
on your life. List and rate.
Extremely
Negative
Event happen in past year?
48.__________________________
NO
YES
q 2
q 1
If Yes…
0 to 6
months
7
months
to 1
year
q 1
q 2
q 1
q 2
If Yes…
Extremely
Negative
Moderately
negative
Somewhat
negative
No Impact
Slightly
positive
Moderately
positive
Extremely
Positive
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q -3
q -2
q -1
q 0
q +1
q +2
q +3
_________________________________________________
_________________________________________________
_________________________________________________
49.__________________________
q 2
q 1
_________________________________________________
_________________________________________________
_________________________________________________
50.__________________________
q 2
q 1
_________________________________________________
_________________________________________________
_________________________________________________
q 1
q 2
Part 2. Students Only
Event happen in past year?
YES
0 to 6
months
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
51. Beginning a new school
experience at a higher
academic level (college,
q 2
graduate school,
professional school, etc.)
53. Academic probation
54. Being dismissed from a
dormitory or other
residence
55. Failing an important
exam
56. Changing a major
57. Failing a course
58.
Dropping a course
If Yes…
7
months
to 1
year
NO
52. Changing to a new
school at same
academic level (undergraduate, graduate,
etc.)
If Yes…
Extremely
Negative
Moderately
negative
Somewhat
negative
No Impact
Slightly
positive
Moderately
positive
Extremely
Positive
Event happen in past year?
59. Joining a fraternity /
sorority
60. Financial problems
concerning school (in
danger of not having
sufficient money to
continue)
If Yes…
If Yes…
NO
YES
0 to 6
months
7
months
to 1
year
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
q 2
q 1
q 1
q 2
q -3
q -2
q -1
q 0
q +1
q +2
q +3
Extremely
Negative
Moderately
negative
Somewhat
negative
No Impact
Slightly
positive
Moderately
positive
Extremely
Positive
| File Type | application/pdf |
| File Title | LES.doc |
| Author | amorusom |
| File Modified | 2005-11-29 |
| File Created | 2003-11-07 |