Personal Injury Psychological Evaluation Questionnaire Form
Please complete this confidential questionnaire to help us understand your psychological experience and needs following your injury.
Full Name
*
First Name
Last Name
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Briefly describe the incident or injury that led to this evaluation.
*
Which of the following psychological symptoms have you experienced since the incident? (Select all that apply)
*
Anxiety
Depressed mood
Sleep difficulties
Irritability/anger
Flashbacks/nightmares
Difficulty concentrating
Other
How severe are your psychological symptoms overall?
*
Not at all severe
1
2
3
4
Extremely severe
5
1 is Not at all severe, 5 is Extremely severe
How often have you experienced these symptoms in the past two weeks?
*
Not at all
Several days
More than half the days
Nearly every day
Have you received any psychological or medical treatment since the incident?
*
Yes, psychological treatment
Yes, medical treatment
Yes, both
No treatment
How much have your symptoms affected your ability to function at work, school, or home?
*
No impact
1
2
3
4
Severe impact
5
1 is No impact, 5 is Severe impact
What current support or resources do you have?
*
Family or friends
Healthcare provider
Community group/support group
None of the above
Other
Is there anything else you would like to share regarding your experience or needs?
Submit
Should be Empty: