PTSD Re-Evaluation Assessment Questionnaire
Please complete this questionnaire to help us re-assess your current PTSD symptoms and related experiences.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Please indicate your gender
*
Male
Female
Non-binary
Prefer not to say
Other
How often have you experienced the following symptoms in the past month?
*
Rows
Never
Rarely
Sometimes
Often
Almost Always
Intrusive memories of the traumatic event(s)
1
2
3
4
5
Nightmares or distressing dreams
6
7
8
9
10
Avoidance of reminders of the trauma
11
12
13
14
15
Negative thoughts or feelings
16
17
18
19
20
Feeling jumpy or easily startled
21
22
23
24
25
In the past month, how would you rate the overall impact of PTSD symptoms on your daily life?
*
No impact
1
2
3
4
5
6
7
8
9
Severe impact
10
1 is No impact, 10 is Severe impact
Have you experienced any significant changes in your symptoms since your last evaluation?
*
Symptoms have improved
Symptoms have worsened
Symptoms have remained the same
Are you currently receiving any treatment for PTSD?
*
Yes
No
If yes, please specify the type(s) of treatment you are receiving (select all that apply):
Therapy/Counseling
Medication
Support groups
Other
Please describe any new or ongoing challenges related to your PTSD symptoms.
Submit Assessment
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