First Name *

Last Name *

Date of birth *

Briefly describe your recent traumatic experience: *

Please answer each of these questions about how you have felt since the event. Choose the answer that indicates how you have felt since the event.

Do you have distressing memories of the trauma when you do not mean to? *

Not at allMildlyMediumQuite a bitVery much

Do you have distressing dreams about the trauma? *

Not at allMildlyMediumQuite a bitVery much

Do you feel as though the trauma is happening again? *

Not at allMildlyMediumQuite a bitVery much

Are you upset or does your body feel uptight when reminded of the trauma? *

Not at allMildlyMediumQuite a bitVery much

Do you have difficulty having positive emotions? *

Not at allMildlyMediumQuite a bitVery much

Do things seem unreal or do you feel distant from your normal self? *

Not at allMildlyMediumQuite a bitVery much

Are you unable to remember an important aspect of trauma not because of head injury or alcohol? *

Not at allMildlyMediumQuite a bitVery much

Do you try to avoid thinking about the trauma? *

Not at allMildlyMediumQuite a bitVery much

Do you try to avoid situations or conversations that remind you of the trauma? *

Not at allMildlyMediumQuite a bitVery much

Do you have trouble falling asleep or staying asleep? *

Not at allMildlyMediumQuite a bitVery much

Do you behave angrily or have temper outbursts? *

Not at allMildlyMediumQuite a bitVery much

Are you on the lookout for danger? *

Not at allMildlyMediumQuite a bitVery much

Do you have problems with concentration? *

Not at allMildlyMediumQuite a bitVery much

Are you jumpy when something surprises you? *

Not at allMildlyMediumQuite a bitVery much

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