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  • new mexico medical cannabis PROGRAM SCREENING FOR PTSD EVAULATION ONLINE

    Zia Health and Wellness. 505-299-7873 740 San Mateo NE 87110 Albuquerque
  • Format: (000) 000-0000.
  •  - -

  • 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)

  • As you go through the list Be sure to consider your entire life (Growing up as well as adulthood
  • Natural disaster example flood hurricane
  • Transportation accident (for example car accident boat or train wreck plane crash)
  • Serious accident at work,home,or during recreational activity ?
  • Exposure to toxic substance ( for example dangerous chemicals, radiation )
  • Physical assault ( for example being attacked,hit,slapped,kicked, beaten up)
  • Assault with a weapon ( for example being shot stabbed threatened with a knife gun or bomb)
  • Sexual assault (rape attempted rape,made to perform any type of sexual act through force or threat of harm
  • Other unwanted or uncomfortable sexual experience
  • Combat or exposure to a war-zone ( in the military as a civilian
  • Captivity (for example being Kidnapped abducted ,held,hostahe prisoner of war)
  • Life -threatening illness or injury
  • Severe human suffering
  • Sudden violent death (for example homicide suicide)
  • Sudden violent death
  • Serious injury ,harm,or death you caused to some one else
  • Any other very stressful event oe experiance

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

     

  • B

    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.)

  • how did you experience it
  • Was someone's life in danger?
  • was someone seriously injured or killed
  • Dit it involve sexual violence
  • If the event involved the death of a close family member or close friend was it due to some kind of accident or violence or was it due to natural causes

  • In the past month,how much were you bothared by

  • Repeated disturbing and unwanted memories of the stressful experience
  • Repeated disturbing dreams of the stressful experience
  • Suddenly feeling or acting as if the stressful experience were actually happening again ( for example as if you were actually back there reliving it ?
  • Feeling vary upset when something reminded you of the stressful experience
  • Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding,trouble breathing ,sweating )
  • Avoiding memories thoughts ,or feelings related to the stressful experience
  • Avoiding external reminders of the stressful experience (for example, people ,places, conversations, activities, objects, or situations
  • Trouble remembering important parts of the stressful experience
  • Having strong negative beliefs about your self,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 id completely dangerous.?
  • Blaming your self or someone else for the stressful experience ?
  • Having strong negative feelings such as, fear,horror,anger,guilt,or shame ?
  • Los of interest in activities that you used to enjoy
  • Feeling distant or cut off from other people
  • Trouble experiencing positive feelings (for example being unable to feel happiness or have loving feelings for people close to you
  • Irritable behavior ,angry,outburst, or acting aggressively?
  • Taking too many risk or doing things that could cause you harm?
  • Being superalert "or watchful or on guard ?
  • Feeling jumpy or easily startled
  • Having difficulty concentrating
  • Having trouble falling or staying asleep?
  • Should be Empty: