First Name Initial*
Middle Name Initial
Last Name Initial*
This questionnaire asks about difficulties due to health conditions. Health conditions include diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems, and problems with alcohol or drugs.
Think back over the past 30 days and answer these questions, thinking about how much difficulty you had doing the following activities. For each question, please circle only one response.
In the past 30 days, how much difficulty did you have in:
S1) Standing for long periods such as 30 minutes?
5Extreme or cannot do
S2) Taking care of your household responsibilities?
S3) Learning a new task, for example, learning how to get to a new place?
S4) How much of a problem did you have joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?
S5) How much have you been emotionally affected by your health problems?
S6) Concentrating on doing something for ten minutes?
S7) Walking a long distance such as a kilometre [or equivalent]?
S8) Washing your whole body?
S9) Getting dressed?
S10) Dealing with people you do not know?
S11) Maintaining a friendship?
S12) Your day-to-day work?
Instruction to patient: Below is a list of problems and complaints that veterans sometimes have in response to stressful life experiences. Please read each one carefully, click on the circle to indicate how much you have been bothered by that problem in the past week.
1) Repeated, disturbing, and unwanted memories of the stressful experience?
1Not at all
2A little bit
4Quite a bit
2) Repeated, disturbing dreams of the stressful experience?
3) Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
4) Feeling very upset when something reminded you of the stressful experience?
5) Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?
6) Avoiding memories, thoughts, or feelings related to the stressful experience?
7) Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?
8) Trouble remembering important parts of the stressful experience?
9) Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?
10) Blaming yourself or someone else for the stressful experience or what happened after it?
11) Having strong negative feelings such as fear, horror, anger, guilt, or shame?
12) Loss of interest in activities that you used to enjoy?
13) Feeling distant or cut off from other people?
14) Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
15) Irritable behavior, angry outbursts, or acting aggressively?
16) Taking too many risks or doing things that could cause you harm?
17) Being “superalert” or watchful or on guard?
18) Feeling jumpy or easily startled?
19) Having difficulty concentrating?
20) Trouble falling or staying asleep?
1. Little interest or pleasure in doing things
1Not at all sure
3Over half the days
4Nearly every day
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed? Or the opposite being so fidgety or restless that you have been moving around more than usual
9. Thoughts that you would be better off dead, or of hurting yourself in some way
10. If you have checked off any of these problems, how difficult have these problems made it for you to do work, take care of things at home, or get along
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worry too much about different things
4. Trouble Relaxing
5. Being so restless that it’s hard to sit still
6. Becoming easily annoyed or irritable
7. Feels afraid as if something awful might happen
If you have checked off any of these problems, how difficult have these problems made it for you to do work, take care of things at home, or get along with people?
© Copyright 2022 Pristine Mental Health. All Rights Reserved. | Site Credits