December 28, 2017 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 did you hear about us? MedicalMarijuanaDoctors.com Searched Google, Bing, or Yahoo Advertisement Word of Mouth Other Would you like to be contacted so we can answer any questions about an official evaluation for PTSD or to schedule one for yourself? Yes No Please feel free to add any additional information regarding your situation in the comment box below. Time is Up!
