Screening for Posttraumatic Stress Disorder (PTSD)

Are you troubled by the following?

You have experienced or witnessed a life-threatening event that caused intense fear, helplessness, or horror.

Yes
No

Do you re-experience the event in any of the following ways?

(check all that apply)

Repeated, distressing memories, or dreams
Acting or feeling as if the event were happening again (flashbacks or a sense of reliving it)
Intense physical and/or emotional distress when you are exposed to things that remind you of the event

Do reminders of the event affect you in at least three of the following ways?

(check all that apply)

Avoiding thoughts, feelings, or conversations about it
Avoiding activities and places or people who remind you of it
Blanking on important parts of it
Losing interest in significant activities of your life
Feeling detached from other people
Feeling your range of emotions is restricted
Sensing that your future has shrunk (for example, you don’t expect to have a career, marriage, children, or normal life span)

Are you troubled by at least two of the following?

(check all that apply)

Problems sleeping
Irritability or outbursts of anger
Problems concentrating
Feeling “on guard”
An exaggerated startle response

Have you experienced changes in sleeping or eating habits?

Yes
No

More days than not, do you feel…

(check all that apply)

sad or depressed?
disinterested in life?
worthless or guilty?

During the last year, has the use of alcohol or drugs…

(check all that apply)

resulted in your failure to fulfill responsibilities with work, school, or family?
placed you in a dangerous situation, such as driving a car under the influence?
gotten you arrested?
continued despite causing problems for you or your loved ones?

Would you like Dr. Harvey to contact you?

If you complete this form a copy of these answers will be emailed to both you and to Dr. Harvey. If you would like Dr. Harvey to contact you please indicate so below.

Yes
No

Name

First

Last

Phone

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Do you suspect that you or a loved one may have PTSD?