PTSD Express Screening -

Name

Email

Phone Number

Do you suffer from insomnia?

Yes

No

Do you often feel like something is wrong, or will go wrong, but you don’t know why?

Yes

No

Does being around a crowd of people make you feel uncomfortable?

Yes

No

Have you experienced or witnessed an event that caused intense fear, helplessness, or horror?

Yes

No

Do you re-experience the event in at least one of the following ways?

Repeated, distressing memories, or dreams

Acting or feeling as if the event were happening again (flashbacks or a sense of reliving it)

Intense physical and/or emotional distress when you are exposed to things that remind you of the event

I do not have any of these symptoms

Do reminders of the event affect you in at least one of the following ways?
If you feel perfectly fine in life don't make a selection

Avoiding thoughts, feelings, or conversations about it

Avoiding activities and places or people who remind you of it

Blanking on important parts of it

Losing interest in significant activities of your life

Feeling detached from other people

Feeling your range of emotions is restricted

Sensing that your future has shrunk (for example, you don't expect to have a career, marriage, children, or normal life span)

Were you raised by one or more parents with mental health or addiction issues?

Yes

No

Have you experienced changes in sleeping or eating habits?

Yes

No

More days than not, do you feel…
If you feel perfectly fine in life don't make a selection

sad or depressed

disinterested in life

worthless or guilty

I am better off dead

During the last year, has the use of alcohol or drugs...
If you feel perfectly fine in life don't make a selection

resulted in your failure to fulfil responsibilities with work, school, or family

placed you in a dangerous situation, such as driving a car under the influence

gotten you arrested

continued despite causing problems for you or your loved ones

doesn't apply to me

Avoid activities or situations because they remind you of a stressful experience from the past?

Never

Rarely

Sometimes

Often

Very Often

Have you ever been incarcerated or arrested?

Yes

No

Have you been in a relationship that felt abusive to you in some way (includes family)?

Yes

No

Have you been prescribed medication, or tried therapy in the past?

No

Yes

Both

If you answered yes or both on the previous question, did therapy or prescriptions help?

Yes

No

50/50

How many major traumatic events have you experienced?

Some traumas are isolated events, like a car accident or the loss of a loved one. For some, you have to use your intuition as to how to differentiate between traumas if necessary. In implementing our therapy we have found that even though one person may have hurt someone many times in the past, our brains tend to generalize the events into one basic trauma. So please count abuse from each person as one separate trauma. You may count multiple events from one time or place in your life if they seem to group together in your imagination. Just go with what you feel. There's no right answer.

1

2-3

4 or more events

Please feel free to add any additional information regarding your situation in the comment box below.

How did you hear about us?

MedicalMarijuanaDoctors.com

Searched Google, Bing, or Yahoo

Word of Mouth

Other

Would you like to be contacted so we can answer any questions about an official evaluation and treatment options for PTSD or to schedule one for yourself?

Yes

No

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