PRIME EVALS

PTSD Self-Assessment Questionnaire

Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem carefully and indicate how much you have been bothered by that problem in the past month.

Personal Information

Please provide your contact details so we can follow up with your results.

First Name *

Last Name *

Email Address *

Phone Number *

Contact Preference *

I would like the PTSD diagnosis as soon as possible.

Please call me as soon as you receive my self test results. I am ready to complete the short phone interview.

I will call your offices when I am ready.

No need to call me at this time. I will reach out to complete the short phone interview.

Assessment Questions

In the past month, how much were you bothered by:

1.Repeated, disturbing, and unwanted memories of the stressful experience?

2.Repeated, disturbing dreams of the stressful experience?

3.Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?

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

5.Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?

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

7.Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?

8.Trouble remembering important parts of the stressful experience?

9.Having strong negative beliefs about yourself, 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 is completely dangerous)?

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

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

12.Loss of interest in activities that you used to enjoy?

13.Feeling distant or cut off from other people?

14.Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?

15.Irritable behavior, angry outbursts, or acting aggressively?

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

17.Being “superalert” or watchful or on guard?

18.Feeling jumpy or easily startled?

19.Having difficulty concentrating?

20.Trouble falling or staying asleep?

By submitting this form, you agree that we will receive a copy of your results and may contact you based on your selected preference.