Patient's Name: __________________________________________
Instruction to patient: Below is a list of problems and complaints that veterans sometimes have in response to stressful military experiences. Please read each one carefully, and put an "X" in the box to indicate how much you have been bothered by that problem in the last month.
Not at all (1)
A little bit (2)
Quite a bit (4)
Repeated, disturbing memories, thoughts or images of a stressful military experience?
Repeated, disturbing dreams about a stressful military experience?
Suddenly acting or feeling as if a stressful military experience were happening again (as if you were reliving it)?
Feeling very upset when something reminded you of a stressful military experience?
Having physical reactions (e.g., heart pounding, trouble breathing or sweating) when something reminded you of a stressful military experience?
Avoid thinking about or talking about a stressful military experience or avoid having feelings related to it?
Avoid activities or situations because they remind you of a stressful military experience?
Trouble remembering important parts of a stressful military experience?
Loss of interest in things that you used to enjoy?
Feeling distant or cutoff from other people?
Feeling emotionally numb or being unable to have loving feelings for those close to you?
Feeling as if your future will somehow be cut short?
Trouble falling or staying asleep?
Feeling irritable or having angry outbursts?
Having difficulty concentrating?
Being super alert or watchful on guard?
Feeling jumpy or easily startled?
Bureau of Medicine and Surgery
7700 Arlington Blvd. Ste. 5113 Falls Church, VA 22042-5113
This is an official U.S. Navy website
This is a Department of Defense (DoD) Internet computer system.
General Navy Medical Inquiries (to Bureau of Medicine and Surgery): firstname.lastname@example.org