36C24118Q0300-002.pdf

October 2016 PTSD Discharge Self Report Form D2

Notice to Veterans: The information requested is confidential and will be used only for the purposes of treatment planning and to assess the performance of the clinical programs. The information is not to be included in your medical record, nor is it to be released to anyone outside the VA unless you make a specific request in writing and sign a release.

1. Date of Admission for Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . (mm/dd/yyyy) / /

2. Date of Discharge from Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . (mm/dd/yyyy) / /

3. Site/Program:

4. Veteran's Name (Last name, First initial) ,

5. Social Security Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - -

I. PSYCHOLOGICAL STATUS

Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem carefully and check the box that indicates how much you have been bothered by that problem since being in this program, or the past 30 days if you have been in the program longer.

6. Repeated, disturbing, and unwanted memories of the stressful experience.

0. Not at all 2. Moderately 4. Extremely

1. A little bit 3. Quite a bit

7. Repeated, disturbing dreams of the stressful experience.

8. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were reliving it).

9. Feeling very upset when something reminded you of the stressful experience.

10. Having strong physical reactions (e.g. heart pounding, trouble breathing, sweating) when something reminded you of the stressful experience.

11. Avoiding memories, thoughts, or feelings related to the stressful experience.

12. Avoiding external reminders of the stressful experience (people, places, conversations, activities, objects, or situations.

13. Trouble remembering important parts of the stressful experience.

For office Use only

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PTSD Discharge Self Report

14. Having strong negative beliefs about yourself, other people, or the world (having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, and the world is completely dangerous).

15. Blaming yourself or someone else for the stressful experience or what happened after it.

16. Having strong negative feelings such as fear, horror, anger, guilt, or shame.

17. Loss of interest in activities that you used to enjoy.

18. Feeling distant or cut off from other people.

19. Trouble experiencing positive feelings (being unable to feel happiness or have loving feelings for people close to you).

20. Irritable behavior, angry outbursts, or acting aggressively.

21. Taking too many risks or doing things that could cause you harm.

22. Being “super alert” or watchful or on guard.

23. Feeling jumpy or easily startled.

24. Having difficulty concentrating.

25. Trouble falling or staying asleep.

The next few questions are about how you have been feeling during the past 30 days. For each question, please give the one answer that comes closest to how often you have felt….

26. Little interest or pleasure in doing things?

0. Not at all 2. More than half the days

1. Several days 3. Nearly every day

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27. Feeling down, depressed or hopeless?

28. Trouble falling asleep, staying asleep, or sleeping too much?

29. Feeling tired or having little energy?

30. Poor appetite or overeating?

31. Feeling bad about yourself or that you’re a failure or have let yourself or your family down?

32. Trouble concentrating on things, such as reading a newspaper or watching television?

33. Moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual?

34. Thoughts that you would be better off dead or of hurting yourself in some way?

35. Feeling nervous, anxious, or on edge?

36. Not being able to stop or control worrying?

37. Worrying too much about different things?

38. Trouble relaxing?

39. Being so restless that it is hard to sit still?

40. Becoming easily annoyed or irritable?

41. Feeling afraid as if something awful might happen?

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II. ALCOHOL AND DRUG USE

Next is a standard set of questions about several areas of your life such as your alcohol and drug use during the past 30 days. If you needed a qualifying period of no substance abuse or were hospitalized during this period then answer for the 30 days prior. Please answer as accurately as possible.

42. In the past 30 days, how many days did you drink ANY alcohol? Include Nyquil, vanilla extract, etc.

1. 0 3. 4-8 5. 16-30

2. 1-3 4. 9-15

43. In the past 30 days, how many days did you have at least 5 drinks (if you are a man) or at least 4 drinks (if you are a woman) within a two or three hour period?

44. In the past 30 days, how many days did you use illegal/street drugs?

45. In the past 30 days, how many days did you use prescription medications (obtained legally or illegally) specifically for the experience or feelings they caused?

46. In the past 30 days, how much were you bothered by cravings or urges to drink alcohol or use drugs?

1. Not at all 3. Moderately 5. Extremely

2. Slightly 4. Considerably

47. How confident are you in your ability to be completely abstinent (clean) from alcohol and drugs for the next 30 days?

1. Not at all 3. Moderately 5. Extremely

2. Slightly 4. Considerably

III. MEDICAL HISTORY

48. In general, how would you say your health is?

1. Excellent 4. Fair

2. Very Good 5. Poor

3. Good

The following two questions are about activities you might do during a typical day. Since being in this program does health now limit you in these activities? If so, how much?

49. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf.

1. Yes, limited a lot 2. Yes, limited a little 3. No, not limited at all

50. Climbing several flights of stairs.

1. Yes, limited a lot 2. Yes, limited a little 3. No, not limited at all

Since being in this program, how much of the time have you had any of the following problems with your work or other regular daily activities as the result of your physical health?

51. Accomplished less than you would like.

1. All of the time 4. A little of the time

2. Most of the time 5. None of the time

3. Some of the time

52. Were limited in the kind of work or other activities.

1. All of the time 4. A little of the time

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Since being in this program, how much of the time have you had any of the following problems with your work or other regular daily activities as the result of any emotional problems such as feeling depressed or anxious?

53. Accomplished less than you would like.

1. All of the time 4. A little of the time

54. Didn’t do work or other activities as carefully as usual.

1. All of the time 4. A little of the time

55. Are you currently experiencing pain that has persisted for three months or longer? 0. No 1. Yes

56. Since being in this program, how much did pain interfere with your normal everyday activities?

1. Not at all 4. Quite a bit

2. A little bit 5. Extremely

3. Moderately

57. What was your average severity of pain during the past week on a 0 (no pain) to 10 (worst pain imaginable) scale?

Pain Severity Rating

58. How satisfied are you with your progress toward achieving your recovery goals?

1. Not at all satisfied 3. Somewhat satisfied 5. Completely satisfied

2. A little bit satisfied 4. Pretty much satisfied

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Thank you for completing this form. If you have any concerns about the questions on the form or your answers please contact your clinician.

If at any time you are experiencing an emotional crisis and want to talk with a mental health professional, call the Veterans Crisis Line at 1-800-273-8255 and after you connect press 1 to reach a Veteran-specific line.