First Name *

Last Name *

Email *

Phone *

PTSD Self Test Part 1/3

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

Not at all

A little bit

Moderately

Quite a bit

Extremely

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

Not at all

A little bit

Moderately

Quite a bit

Extremely

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

Not at all

A little bit

Moderately

Quite a bit

Extremely

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

Not at all

A little bit

Moderately

Quite a bit

Extremely

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

Not at all

A little bit

Moderately

Quite a bit

Extremely

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

Not at all

A little bit

Moderately

Quite a bit

Extremely

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

Not at all

A little bit

Moderately

Quite a bit

Extremely

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

Not at all

A little bit

Moderately

Quite a bit

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)? *

Not at all

A little bit

Moderately

Quite a bit

Extremely

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

Not at all

A little bit

Moderately

Quite a bit

Extremely

PTSD Self Test Part 2/3

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

Not at all

A little bit

Moderately

Quite a bit

Extremely

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

Not at all

A little bit

Moderately

Quite a bit

Extremely

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

Not at all

A little bit

Moderately

Quite a bit

Extremely

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

Not at all

A little bit

Moderately

Quite a bit

Extremely

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

Not at all

A little bit

Moderately

Quite a bit

Extremely

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

Not at all

A little bit

Moderately

Quite a bit

Extremely

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

Not at all

A little bit

Moderately

Quite a bit

Extremely

18. Feeling jumpy or easily startled? *

Not at all

A little bit

Moderately

Quite a bit

Extremely

19. Having difficulty concentrating? *

Not at all

A little bit

Moderately

Quite a bit

Extremely

20. Trouble falling or staying asleep? *

Not at all

A little bit

Moderately

Quite a bit

Extremely

PTSD Self Test Part 3/3

How would you qualify your trauma? *

Motor vehicle Trauma (trauma related to a vehicular accident)

Accidental trauma (accidental camping, hunting, firearm or other trauma)

Physical domestic abuse trauma (physical spousal abuse, physical childhood abuse, physical abuse by relative)

Sexual abuse trauma (sexual assault, molestation, or unwanted physical sexual advances)

Psychological abuse trauma (mental or verbal abuse)

Law enforcement abuse trauma (incidents related to abuse of power, where you felt threatened or unsafe at the hands of law enforcement)

Religious trauma (victim of strange or extreme religious circumstances)

Violent crime trauma (being a victim of a violent crime)

Incarceration trauma (trauma from being incarcerated)

Military Service trauma (trauma resulting from service in the armed forces)

Other

How would you classify your trauma? *

History of Traumatic Incident(s)

Please provide a thorough history describing the traumatic event or series of events that caused your symptoms of PTSD: *

I certify that the history provided here is true and accurate to the best of my knowledge *

Yes

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