52. Do you have, or have you had in the past, problems with any of the following?
Hearing
Vision
Head Injury
Emotional Trauma
Headaches
YesNo
Allergies
Drug Abuse
Alcohol Abuse
Ear Infections
Migraines
YesNo
If yes, please describe ____________________________________________________________
______________________________________________________________________________
53. Have you had a history of depression, anxiety or other emotional or psychological
difficulties (for example: OCD, school phobia, suicide attempts?)
Yes
No
No
Have you ever taken medication for this condition?
Yes
No
No
If yes, please give details: _________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Employment
54. Of all the jobs (both paid and unpaid) you have worked at, what type of work did you enjoy the most?
______________________________________________________________________________
______________________________________________________________________________
55. Explain any problems that you have that affect the type of jobs that you get, or that keep
you from getting jobs that you would like to have.
______________________________________________________________________________
______________________________________________________________________________
56. If you are currently working, how many hours are you working per week? _____________
