36C24118Q0300-003.pdf

October 2016 PTSD Admission Self Report Form A2

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. Site/Program:

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

4. Social Security Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - -

I. MILITARY

5. Are you currently on an active tour of duty? 0. No 1. Yes

6. During what years were you on active duty? (Check all that apply)

1. Pre-WW II (before 12/7/1941) 6. Vietnam Era (2/28/1961-5/7/1975)

2. World War II (12/7/1941-12/31/1946) 7. Post-Vietnam Era (5/8/1975-8/1/1990)

3. Pre-Korean Conflict (1/1/1947-6/26/1950) 8. Persian Gulf War (8/2/1990-9/10/2001)

4. Korean Conflict (6/27/1950-1/31/1955) 9. OIF/OEF/OND (9/11/2001-Present)

5. Between Korea and Vietnam Eras (2/1/1955-2/27/1961)

7. How many times have you been deployed to an area where you received hazardous duty pay? (0=never)

8. Did you ever receive friendly or hostile incoming fire from small arms, artillery, rockets, mortars or bombs? (Do not include gunfire, etc. experienced while a civilian or not while on active duty). 0. No 1. Yes

9. Which type of traumatic incident (include both military and non-military) have you suffered within your lifetime?

(Check all that apply)

1. Military Sexual Trauma 5. Victim of violence (e.g. child abuse)

2. Non-Military Sexual Trauma 6. Natural disaster

3. Vehicle accident 7. Other

4. Other Accident 8. None

II. 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 in the last month.

10. 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

11. Repeated, disturbing dreams of the stressful experience.

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

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

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PTSD Admission Self Report

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

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

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

17. Trouble remembering important parts of the stressful experience.

18. 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).

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

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

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

22. Feeling distant or cut off from other people.

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

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

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

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

27. Feeling jumpy or easily startled.

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28. Having difficulty concentrating.

29. 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….

30. Little interest or pleasure in doing things?

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

1. Several days 3. Nearly every day

31. Feeling down, depressed or hopeless?

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

33. Feeling tired or having little energy?

34. Poor appetite or overeating?

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

36. Trouble concentrating on things, such as reading the newspaper or watching television?

37. 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?

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

39. Feeling nervous, anxious, or on edge?

40. Not able to stop or control worrying?

41. Worrying too much about different things?

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42. Trouble relaxing?

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

44. Becoming easily annoyed or irritable?

45. Feeling afraid as if something awful might happen?

III. 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.

46. 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

47. 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?

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

49. 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?

50. 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

51. If you were not admitted to this program, how confident would you be in your ability to be completely abstinent (clean) from alcohol and drugs for 30 days?

1. Not at all 3. Moderately 5. Extremely

2. Slightly 4. Considerably

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IV. MEDICAL HISTORY

52. 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. Does health now limit you in these activities? If so, how much?

53. 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

54. Climbing several flights of stairs.

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

During the past month, 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?

55. 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

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

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

During the past month, 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?

57. Accomplished less than you would like.

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

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

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

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

60. During the past month, how much did pain interfere with your normal work including both work outside the home and housework?

1. Not at all 4. Quite a bit

2. A little bit 5. Extremely

3. Moderately

61. 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

62. Do you attribute your pain problem to the same experience that you believe caused your PTSD?

0. No 1. Yes 2. No pain problem

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63. 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

V. DESCRIPTION AND BACKGROUND

64. Date of Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(mm/dd/yyyy) / /

65. What was your sex assigned at birth? 1. Male 2. Female 3. Prefer not to answer

66. How do you identify your gender (gender identity)? (Check one)

1. Man 3. Transgender man (female-to-male) 5. Other

2. Woman 4. Transgender woman (male-to-female) 6. Prefer not to answer

67. Do you think of yourself as: (Check one)

1. Lesbian, gay, or homosexual 3. Bisexual 5. Don’t know

2. Straight or heterosexual 4. Something Else 6. Prefer not to answer

68. Is your mental health provider aware of and sensitive to your sexual orientation and/or gender identity? (Check one)

1. Strongly disagree 3. Neither agree nor disagree 5. Strongly agree

2. Somewhat disagree 4. Somewhat agree 6. Prefer not to answer

69. Marital Status (Check one)

1. Married /Domestic Partner 3. Widowed 5. Divorced 7. Prefer not to answer

2. Remarried 4. Separated 6. Never Married

70. Race/Ethnic Ancestry (Check all that apply)

1. White, not Hispanic 4. Hispanic, Black 7. Pacific Islander

2. Black, not Hispanic 5. American Indian/Alaskan 8. Other

3. Hispanic, White 6. Asian 9. Prefer not to answer

71. What is your living arrangement at the time of admission to this program? (Check one)

1. Apt or house owned/rented by you 5. Shelter, drop-in center

2. Other persons apt or house 6. Jail or prison

3. Hotel or motel you pay for 7. Street, automobile, outdoors

4. Hospital treatment program

72. Number of years of education completed. (GED=12)

73. Were you working before admission to this Program? (Check one)

0. No 1. Part-time 2. Full-time

73A. If NO, What is the major reason? (Check one)

1. Retired 5. Not looking for work due to mental health concern

2. Certified 100% disabled 6. Not looking for work due to other obligations

3. Partially disabled (receive SSD or 7. Not looking for work - student less than 100%) 8. Not looking for work by choice

4. Looking for work, unable to find a job

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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.