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?
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* Intrusive thoughts and images
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* Recurring dreams, nightmares
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* Flashbacks
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* Anxiety attacks
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* Crying spells and tearfulness
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* Feelings of shame, embarrassment
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* Guild Feelings (“If only...”)
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* Withdrawal
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* Depression – diminished interest
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* Feeling of detachment or estrangement
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* Inability to recall specific events of trauma
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* Disorientation, confusion
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* Restricted effect
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* Avoidance of thoughts of trauma
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* Fear
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* Job difficulties
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* Family, interpersonal difficulties
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* Sexual dysfunction
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* Numbness – emotional / physical
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* Helplessness, loss of control
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* Sleep disturbances
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* Anger / Rage
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* Difficulty in concentrating
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* Hypervigilance
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* High startle response
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* Headaches
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* Muscle tension
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* Nausea
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* Eating disturbances
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* Difficulty in breathing
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* Cold sweat
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* Increased use of alcohol
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* Increased use of drugs
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Presently taking medication? Yes: _______ No: _________Explain: _________________________________________________________
Specific Health Problems:
Explain: __________________________________________________________
Doctor: __________________________________________________________