Psychology/Post Trauma Stress Assessment

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Post-Traumatic Stress Assessment

Date: ___________________


Client Name:_____________________


Trauma: ________________________ Date of 1st Instance: ____________________________


Since the trauma, which of the following is being experienced, and how frequently?


Symptom
Frequently
(3-5x/week)
Occasional
(1-2x/wk)
Seldom
(1x/wk)
Never
0
INTRUSION


* Intrusive thoughts and images


* Recurring dreams, nightmares


* Flashbacks


* Anxiety attacks


* Crying spells and tearfulness


* Feelings of shame, embarrassment


* Guild Feelings (“If only...”)


WITHDRAWAL


* Withdrawal


* Depression – diminished interest


* Feeling of detachment or estrangement


* Inability to recall specific events of trauma


* Disorientation, confusion


* Restricted effect


* Avoidance of thoughts of trauma


* Fear


* Job difficulties


* Family, interpersonal difficulties


* Sexual dysfunction


* Numbness – emotional / physical


* Helplessness, loss of control


AROUSAL


* Sleep disturbances


* Anger / Rage


* Difficulty in concentrating


* Hypervigilance


* High startle response


* Headaches


* Muscle tension


* Nausea


* Eating disturbances


* Difficulty in breathing


* Cold sweat


* Increased use of alcohol


* Increased use of drugs


Presently taking medication? Yes: _______ No: _________Explain: _________________________________________________________


Specific Health Problems:

Explain: __________________________________________________________

Doctor: __________________________________________________________