PTSD Study Post Survey

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone *

Date / Time *

Date

Time

Instructions: Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem carefully and then select one of the answers that best indicates how much you have been bothered by that problem in the past month.

1 – Repeated, disturbing, and unwanted memories of the stressful experience? *

2 – Repeated, disturbing dreams of the stressful experience? *

3 – Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)? *

4 – Feeling very upset when something reminded you of the stressful experience? *

5 – Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)? *

6 – Avoiding memories, thoughts, or feelings related to the stressful experience? *

7 – Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)? *

8 – Trouble remembering important parts of the stressful experience? *

9 – Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)? *

10 – Blaming yourself or someone else for the stressful experience or what happened after it? *

11 – Having strong negative feelings such as fear, horror, anger, guilt, or shame? *

12 – Loss of interest in activities that you used to enjoy? *

14 – Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)? *

15 – Irritable behavior, angry outbursts, or acting aggressively? *

16 – Taking too many risks or doing things that could cause you harm? *

21 – On average, how many times a week did you use the device? *

22 – On average, do you feel you were properly hydrated before each session? (Hydrated = a liter of water in the preceding 4 hours before a session) *

0 – Yes
1 – No

Did you experience any side effects from the therapy? (None have been reported in the past, but we want to make sure.)

In your own words, how did the Pulsar XO help with your PTSD? *

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