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1. 
What is your Race?
 
Caucasian
 
Black-American
 
Asian
 
Phillipian
 
Other
 

 
2. 
What is your Gender?
 
Male
 
Female

 
3. 
Do you or have you used Alcohol?
 
Yes
 
No

 
4. 
If Yes, What are your reasons for using Alcohol?
 
Social Drinking
 
Daily Drinking
 
Binge Drinking
 
Occasional Drinking Approximately 4 times a month.
 
Experimental once or twice a year
 
Other

 
 
My academic efforts and schoolwork causes this level of stress for me
   
 
 
My job causes this level of stress for me
   
 
 
My family causes me this level of stress
   
 
 
My daily financial situation causes me to have this amount of stress
   
 
9. 
As a child were you a witness to any child abuse?
 
yes
 
no

 
10. 
As a child were you ever a victim of child abuse?
 
Yes
 
No, if no please skip the next question.

 
11. 
Did it seem as though the abuse was caused from one of the following?
 
Stress from Work
 
Stress from Family
 
Stress from Money
 
Alcoholic Influences
 
Discipline Nature

 
12. 
Did you ever discuss these issues of abuse with your parents?
 
Yes
 
No

 
13. 
Did you ever discuss these issues with your friends?
 
Yes
 
No

 
14. 
Did you ever seek help from the law or from a social assistance agency?
 
Yes
 
No

 
15. 
Were there ever-visual signs of abuse?
 
Yes
 
No

 
16. 
Which of these do you believe is tolerable disciplinary actions by a parent?
 
Verbal Warning
 
Smack on the hand
 
Time Out
 
Groundings
 
Spankings
 
Facial Smacking
 
Body Punches
 
Being Hit with Objects
 
Other
 

 
17. 
As a parent, would you use abusive measures to discipline a child?
 
Yes
 
No

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