1 Survey

Appendix A A.2.1.l–4

Life Experiences Survey¹

Listed below are some things that might have occurred to you since you became pregnant.

Please circle yes for those items you have experienced since you became pregnant, and circle no if you have not experienced the item.

If you circle yes, then circle one of the next numbers to show whether you think this had a negative or bad impact, or a positive or good impact.

For example, circle -3 if it was an extremely negative or bad impact. Circle 0 if you thought there was no impact. Circle +3 to indicate an extremely positive impact.

			Negative/Bad or Positive/Good Impact on your life?
			---Negative/Bad---				---Positive/Good---
	SINCE YOU BECAME PREGNANT, HAVE YOU:		extremely negative	moderately negative	somewhat negative	no impact	somewhat positive	moderately positive	extremely positive
1	Gotten married?	no yes 	-3	-2	-1	0	+1	+2	+3
2	Been in jail or similar institution?	no yes 	-3	-2	-1	0	+1	+2	+3
3	Had your husband or boyfriend die?	no yes 	-3	-2	-1	0	+1	+2	+3
4	Had a major change in sleeping habits (much more sleep or much less sleep)?	no yes 	-3	-2	-1	0	+1	+2	+3
5	Experienced the death of a close family member (your child, father, mother, sister, brother, grandparent or other)?	no yes 	-3	-2	-1	0	+1	+2	+3
6	Had a major change in your eating habits (ate much more or less food)?	no yes 	-3	-2	-1	0	+1	+2	+3
7	Experienced a foreclosure on a mortgage or a loan?	no yes 	-3	-2	-1	0	+1	+2	+3
8	Experienced the death of a close friend?	no yes 	-3	-2	-1	0	+1	+2	+3
9	Had an outstanding personal achievement?	no yes 	-3	-2	-1	0	+1	+2	+3
10	Had a minor law violation (such as a traffic ticket or disturbing the peace)?	no yes 	-3	-2	-1	0	+1	+2	+3
11	Changed your work situation (such as a different work responsibility, a major change in working conditions or working hours)?	no yes 	-3	-2	-1	0	+1	+2	+3
12	Started a new job?	no yes 	-3	-2	-1	0	+1	+2	+3
13	Had one of your close family members have a serious illness or injury (your husband/boyfriend, child, father, mother, sister, brother, grandparent or other)?	no yes 	-3	-2	-1	0	+1	+2	+3
14	Had sexual difficulties?	no yes 	-3	-2	-1	0	+1	+2	+3
15	Had trouble with your boss (such as you were in danger of losing your job, being suspended, or demoted)?	no yes 	-3	-2	-1	0	+1	+2	+3
16	Had trouble with your in-laws?	no yes 	-3	-2	-1	0	+1	+2	+3
17	Had a major change in your financial status (a lot better off or a lot worse off)?	no yes 	-3	-2	-1	0	+1	+2	+3
18	Had a major change in closeness of family members (increased or decreased closeness)?	no yes 	-3	-2	-1	0	+1	+2	+3
19	Gained a new family member (through adoption, or a family member moving in, not including your pregnancy)?	no yes 	-3	-2	-1	0	+1	+2	+3
20	Moved to a new place?	no yes 	-3	-2	-1	0	+1	+2	+3
21	Had a separation from your husband or boyfriend because you were not getting along?	no yes 	-3	-2	-1	0	+1	+2	+3
22	Had a major change in church activities (increased or decreased attendance)?	no yes 	-3	-2	-1	0	+1	+2	+3
23	Gotten back together with your husband or boyfriend after a separation?	no yes 	-3	-2	-1	0	+1	+2	+3
24	Had a major change in number of arguments you have with your husband or boyfriend (a lot more or a lot fewer arguments)?	no yes 	-3	-2	-1	0	+1	+2	+3
25	Had a change in your husband’s or boyfriend’s work (he lost his job or started a new job)?	no yes 	-3	-2	-1	0	+1	+2	+3
26	Had a major change in usual type and/or amount of recreation?	no yes 	-3	-2	-1	0	+1	+2	+3
27	Borrowed more than $15,000 (such as buying a home or business)?	no yes 	-3	-2	-1	0	+1	+2	+3
28	Borrowed less than $15,000 (such as buying car or getting a school loan)?	no yes 	-3	-2	-1	0	+1	+2	+3
29	Been fired from a job?	no yes 	-3	-2	-1	0	+1	+2	+3
30	Had a major personal illness or injury?	no yes 	-3	-2	-1	0	+1	+2	+3
31	Had a major change in social activities, such as parties, movies, visiting, either increased or decreased?	no yes 	-3	-2	-1	0	+1	+2	+3
32	Had a major change in living conditions of your family (built a new home, remodeled, had your home or neighborhood decline)?	no yes 	-3	-2	-1	0	+1	+2	+3
33	Gotten a divorce?	no yes 	-3	-2	-1	0	+1	+2	+3
34	Had a close friend with a serious injury or illness?	no yes 	-3	-2	-1	0	+1	+2	+3
35	Had a son or daughter leave home because of a marriage or school?	no yes 	-3	-2	-1	0	+1	+2	+3
36	Dropped out or graduated from school?	no yes 	-3	-2	-1	0	+1	+2	+3
37	Had a separation from your husband or boyfriend because of work, travel, or family needs?	no yes 	-3	-2	-1	0	+1	+2	+3
38	Gotten engaged to be married?	no yes 	-3	-2	-1	0	+1	+2	+3
39	Left home for the first time?	no yes 	-3	-2	-1	0	+1	+2	+3

1 Sarason IG, Johnson JH, Siegel JM. Assessing the impact of the life experiences survey. J Consult Clin Psychol 1978;46:932-46.