PTSD Disability Evaluation Questionnaire Form
Complete this assessment to evaluate PTSD-related symptoms and their impact on daily functioning. Please answer each question based on your current experience.
Full Name
*
First Name
Last Name
How often have you experienced unwanted memories of the traumatic event(s) in the past month?
*
Not at all
Several days
More than half the days
Nearly every day
In the past month, how often have you had nightmares related to the traumatic event(s)?
*
Not at all
Several days
More than half the days
Nearly every day
How much have you tried to avoid thoughts, feelings, or conversations about the traumatic event(s)?
*
Not at all
A little bit
Moderately
Extremely
Please rate the severity of the following symptoms in the past month.
*
Rows
Not at all
Mild
Moderate
Severe
Feeling distant or cut off from others
1
2
3
4
Difficulty concentrating
5
6
7
8
Irritability or angry outbursts
9
10
11
12
Exaggerated startle response
13
14
15
16
How much have PTSD symptoms interfered with your ability to function at work, school, or in social situations?
*
No interference
0
1
2
3
4
5
6
7
8
9
Extreme interference
10
0 is No interference, 10 is Extreme interference
Have you received any treatment for PTSD (e.g., therapy, medication) in the past year?
*
Yes
No
Please describe any other symptoms or concerns related to PTSD that you feel are important.
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Assessment
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