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PTSD Treatment Study Pre Survey

Please fill out this form completely for our PTSD Therapy Study.

– Step 1 of 3

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone *

Date / Time *

Date

Time

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? *

0 – Not at all
1 – A little bit
2 – Moderately
3 – Quite a bit
4 – Extremely

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

0 – Not at all
1 – A little bit
2 – Moderately
3 – Quite a bit
4 – Extremely

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

0 – Not at all
1 – A little bit
2 – Moderately
3 – Quite a bit
4 – Extremely

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

0 – Not at all
1 – A little bit
2 – Moderately
3 – Quite a bit
4 – Extremely

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

0 – Not at all
1 – A little bit
2 – Moderately
3 – Quite a bit
4 – Extremely

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

0 – Not at all
1 – A little bit
2 – Moderately
3 – Quite a bit
4 – Extremely

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

0 – Not at all
1 – A little bit
2 – Moderately
3 – Quite a bit
4 – Extremely

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

0 – Not at all
1 – A little bit
2 – Moderately
3 – Quite a bit
4 – Extremely

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)? *

0 – Not at all
1 – A little bit
2 – Moderately
3 – Quite a bit
4 – Extremely

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

0 – Not at all
1 – A little bit
2 – Moderately
3 – Quite a bit
4 – Extremely

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

0 – Not at all
1 – A little bit
2 – Moderately
3 – Quite a bit
4 – Extremely

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

0 – Not at all
1 – A little bit
2 – Moderately
3 – Quite a bit
4 – Extremely

13 – Feeling distant or cut off from other people? *

0 – Not at all
1 – A little bit
2 – Moderately
3 – Quite a bit
4 – Extremely

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

0 – Not at all
1 – A little bit
2 – Moderately
3 – Quite a bit
4 – Extremely

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

0 – Not at all
1 – A little bit
2 – Moderately
3 – Quite a bit
4 – Extremely

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

0 – Not at all
1 – A little bit
2 – Moderately
3 – Quite a bit
4 – Extremely

17 – Being “superalert” or watchful or on guard? *

0 – Not at all
1 – A little bit
2 – Moderately
3 – Quite a bit
4 – Extremely

18 – Feeling jumpy or easily startled? *

0 – Not at all
1 – A little bit
2 – Moderately
3 – Quite a bit
4 – Extremely

19 – Having difficulty concentrating? *

0 – Not at all
1 – A little bit
2 – Moderately
3 – Quite a bit
4 – Extremely

20 – Trouble falling or staying asleep? *

0 – Not at all
1 – A little bit
2 – Moderately
3 – Quite a bit
4 – Extremely

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