Please enable JavaScript in your browser to complete this form.
On a scale of 1 - 5
1 = Never
2 = Rarely
3 = Occasionally
4 = Frequently
5 = Always
Hypervigilance (being on guard at all times)
Selected Value:
1
Intrusive imagery or flashbacks
Selected Value:
1
Number Extreme sensitivity to light and sound
Selected Value:
1
Hyperactivity
Selected Value:
1
Exaggerated emotional and startle responses
Selected Value:
1
Nightmares and night terrors
Selected Value:
1
Abrupt mood swings
Selected Value:
1
Reduced ability to deal with stress
Selected Value:
1
Difficulty falling or staying asleep
Selected Value:
1
Panic attacks or anxiety
Selected Value:
1
Difficulty concentrating
Selected Value:
1
Avoiding certain places or circumstances
Selected Value:
1
Attraction to dangerous situations
Selected Value:
1
Frequent crying
Selected Value:
1
Exaggerated or diminished sexual activity
Selected Value:
1
Amnesia and/or forgetfulness
Selected Value:
1
Inability to love, nurture or bond with others
Selected Value:
1
Fear of dying or having a shortened life
Selected Value:
1
Fear of going crazy
Selected Value:
1
Inability to make commitments
Selected Value:
1
Chronic fatigue or very low physical energy
Selected Value:
1
Headaches
Selected Value:
1
Neck and back problems
Selected Value:
1
Asthma
Selected Value:
1
Digestive problems, colitis, spastic colon
Selected Value:
1
Depression, feeling of impending doom
Selected Value:
1
Feelings of detachment, alienation, & isolation
Selected Value:
1
Need alcohol or drugs to relax
Selected Value:
1
Spaciness or mental blankness
Selected Value:
1
Spaciness or mental blankness
Selected Value:
1
Feelings of helplessness
Selected Value:
1
Freezing or immobility response to danger
Selected Value:
1
Name
*
First
Last
Email
*
Submit
