Partner Violence/PTSD Screening

Name

First NameLast Name

Today's Date

Date of Birth

If you are currently in a relationship, how often does your partner...

Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example:

A serious car accident or fire, physical or sexual assault/abuse, natural disaster, death of a loved one through homicide or suicide, or war.

Have you ever experienced this kind of event?

YesNo

In the past month, have you:

	Yes	No
Had nightmares about the event(s) or thought about the event(s) when you did not want to?
Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)?
Been constantly on guard, watchful, or easily startled?
Felt numb or detached from others, activities, or surroundings?
Felt guilty or felt unable to stop blaming yourself or others for the event(s) or any problems that event(s) may have caused?