First Name

Last Name

Address

Street Address

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Phone *

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Date of birth

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Do you have children? If so, how many do you have?:

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Check all ways PTSD interferes with your daily life:

I forget to eat, bathe, or take medications

I stay in bed or inside most days

I need reminders or help with basic tasks

I can’t go into stores, public places, or crowded areas

I’ve withdrawn from family, children, and friends

I feel emotionally numb or disconnected most of the time

I experience breakdowns or panic over small stressors

Only get 3-4 hours of sleep

Markers After Trauma. Check all statements that apply to your current situation:

Requested transfer or reassignment

Drop in performance or fitness evaluations

Disciplinary actions or Article 15s/NJP

Increase in sick call visits or unexplained physical symptoms

Changes in relationships or isolation

Substance use or drinking to cope

Reports to Chaplain, medical, or peers about emotional distress

No report made at the time due to fear or shame

Check all that apply to your treatment efforts:

VA therapy or mental health services

Civilian psychiatrist, psychologist, or counselor

Group therapy or PTSD programs

Psychiatric medications

Suicide prevention or crisis stabilization services

I have not received treatment due to fear, stigma, or lack of access

I attempted treatment but could not continue due to symptoms worsening

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Auditory Hallucinations (Hearing)

I hear voices that no one else hears

I hear my name being called when no one is there

I hear conversations, music, or shouting in my head

I hear a voice or inner commentary that criticizes or commands me

I hear footsteps, knocking, or sounds that aren’t real

Visual Hallucinations (Seeing)

I see shadows, figures, or flashes of light others don’t see

I see people or animals that are not really there

I see movement or shapes in my peripheral vision that disappear when I look

I have visual flashbacks that seem real (like reliving the trauma)

Olfactory Hallucinations (Smelling)

I smell things (burning, body odor, chemicals, blood, etc.) that others can’t

I get phantom smells that remind me of traumatic events (e.g., smoke, burning flesh)

Gustatory Hallucinations (Tasting)

I taste blood, chemicals, or foul substances that aren’t present

I experience metallic or rotten tastes without a source

Tactile Hallucinations (Touch/Physical Sensations)

I feel bugs crawling on or under my skin

I feel touched or grabbed when no one is near me

I feel pain or pressure with no medical cause

I get the sensation of being pushed or pulled by something unseen

Disconnected Reality / Dissociative Symptoms

I feel like I’m outside my body watching myself (depersonalization)

I feel like the world around me isn’t real (derealization)

I can’t tell what’s real vs. imagined during episodes

I experience time distortion or memory blackouts

I’ve spoken to or responded to someone I later realized wasn’t real

I become confused about what’s real during flashbacks

I feel like I’m being watched or followed

I hide these symptoms out of embarrassment or fear

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