Form for PTSD

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iNSTRUCTIONS:

listed below are a number of stressful or difficult things that some times happen to people. For each event check one or more of the boxes to the right to indicate that:(a) it happen to you personaly;(b) you witnessed it happen to some one else (c) you learned about it happening to a close family member or close friend (d) you was exposed to it as part of your job( for example ,Paramedic,Police,Military or other first responder (e) your not sure if it fits; or doesent apply to you.

Please tell us about your tramitic event that may have caused (PTSD)

A. if you checked any thing for #17 in part 1 briefly identify the event you were thinking of

If you experienced more than one of the events in part 1 think about the worst event which for this questionnair means the event that currently bothers you the most. If you have experienced only one of the events in part 1, use that one as the worst event .Please answer the following queastions about the worst event ( check all that apply

Breifly describe the worst event ( for example what happend , who was invalved etc.)

It happen to me directlyI learned about it happening to a close family member or close friendI was repeatedly exposed to details about it as part of my job (for example paramedic ,police,military, or other first responder

Yes my lifeyes someone else's lifeNo

yes i was seriously injuredyes someone else was seriously injured or killedNo

Accident or violencenatural causesNot applicable ( the event did not involve the death of a close family member or close friend

In the past month,how much were you bothared by

Not at allA little bitModeratelyExtremely

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