Initial PTSD Questionnaire

Address

Street Address

City

State

Postal Code

Do you receive any type of Separation / Severance / Retired Pay?

Yes

No

If YES, list amount and type (if known)

Stressor Information

Unit at time of Stressor 1 *

Stressor 1 ( Write a summary of the events that transpired during the stressor event in as much detail as possible)

Rank and Name of any injured or KIA

Stressor 2 ( Write a summary of the events that transpired during the stressor event in as much detail as possible)

Please list prescriptions and medications.

Please explain your education and work history. *

Any legal or behavioral history? *

Yes

No

If you have legal or behavioral history, please explain: *

History of substance abuse? *

Yes

No

If you have history of substance abuse, please explain: *

Previous treatment or diagnosis of a mental health condition? *

Yes

No

If you have previous treatment or diagnosis of a mental health condition?, please explain: *

Is there a specific event or situation in service that you feel has affected your mood? *

Yes

No

if there's specific event or situation in service that you feel has affected your mood?, please explain: *

1. *

2. *

3. *

4. *

5. *

6. *

7. *

8. *

9. *

10. *

11. *

12. *

13. *

14. *

15. *

16. *

17. *

18. *

19. *

20. *

21. *

1. Repeated, disturbing memories, thoughts, or images of a stressful military experience?

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

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

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

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?

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

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