December 28, 2017 PTSD Screening Quiz First 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 Advertisement Word of Mouth Other Would you like to be contacted? I would like to be sent the results & evaluated for a PTSD diagnosis as soon as possible so I can get my medical use card and am ready to complete the short phone interview. Please call/text me as soon as you receive my self test results. I would like to be sent the results and contacted so we can answer any questions about an official evaluation and treatment options for PTSD or to schedule one for yourself? No Time is Up! Time's up
