Questionnaire (PTSD)

Hello! Please click the button below to complete a short questionnaire. Doing this regularly is one way we can track how therapy is going. Your responses will be emailed directly to Dr Forzisi.

The Impact of Event Scale - Revised
Below is a list of difficulties people sometimes have after stressful life events. Please read each item, and then indicate how distressing each difficulty has been for you DURING THE PAST SEVEN DAYS with respect to __________________________________, how much were you distressed or bothered by these difficulties?
Any reminder brought back feelings about it
0 = Not at all, 1 = A little bit, 2 = Moderately, 3 = Quite a bit, 4 = Extremely
I had trouble staying asleep
0 = Not at all, 1 = A little bit, 2 = Moderately, 3 = Quite a bit, 4 = Extremely
Other things kept making me think about it
0 = Not at all, 1 = A little bit, 2 = Moderately, 3 = Quite a bit, 4 = Extremely
I felt irritable and angry
0 = Not at all, 1 = A little bit, 2 = Moderately, 3 = Quite a bit, 4 = Extremely
I avoided letting myself get upset when I thought about it or was reminded of it
0 = Not at all, 1 = A little bit, 2 = Moderately, 3 = Quite a bit, 4 = Extremely
I thought about it when I didn’t mean to
0 = Not at all, 1 = A little bit, 2 = Moderately, 3 = Quite a bit, 4 = Extremely
I felt as if it hadn’t happened or wasn’t real
0 = Not at all, 1 = A little bit, 2 = Moderately, 3 = Quite a bit, 4 = Extremely
I stayed away from reminders about it
0 = Not at all, 1 = A little bit, 2 = Moderately, 3 = Quite a bit, 4 = Extremely
Pictures about it popped into my mind
0 = Not at all, 1 = A little bit, 2 = Moderately, 3 = Quite a bit, 4 = Extremely
I was jumpy and easily startled
0 = Not at all, 1 = A little bit, 2 = Moderately, 3 = Quite a bit, 4 = Extremely
I tried not to think about it
0 = Not at all, 1 = A little bit, 2 = Moderately, 3 = Quite a bit, 4 = Extremely
I was aware that I still had a lot of feelings about it, but I didn’t deal with them
0 = Not at all, 1 = A little bit, 2 = Moderately, 3 = Quite a bit, 4 = Extremely
My feelings about it were kind of numb
0 = Not at all, 1 = A little bit, 2 = Moderately, 3 = Quite a bit, 4 = Extremely
I found myself acting or feeling as though I was back at that time
0 = Not at all, 1 = A little bit, 2 = Moderately, 3 = Quite a bit, 4 = Extremely
I had trouble falling asleep
0 = Not at all, 1 = A little bit, 2 = Moderately, 3 = Quite a bit, 4 = Extremely
I had waves of strong feelings about it
0 = Not at all, 1 = A little bit, 2 = Moderately, 3 = Quite a bit, 4 = Extremely
I tried to remove it from my memory
0 = Not at all, 1 = A little bit, 2 = Moderately, 3 = Quite a bit, 4 = Extremely
I had trouble concentrating
0 = Not at all, 1 = A little bit, 2 = Moderately, 3 = Quite a bit, 4 = Extremely
Reminders of it caused me to have physical reactions, such as sweating, trouble breathing, nausea, or a pounding heart
0 = Not at all, 1 = A little bit, 2 = Moderately, 3 = Quite a bit, 4 = Extremely
I had dreams about it
0 = Not at all, 1 = A little bit, 2 = Moderately, 3 = Quite a bit, 4 = Extremely
I felt watchful or on-guard
0 = Not at all, 1 = A little bit, 2 = Moderately, 3 = Quite a bit, 4 = Extremely
I tried not to talk about it
0 = Not at all, 1 = A little bit, 2 = Moderately, 3 = Quite a bit, 4 = Extremely
PLEASE RATE HOW YOU HAVE FELT ABOUT THE TRAUMATIC EVENT IN THE PAST WEEK:
To what extent do you think you have come to terms with the trauma?
100 = Completely, 0 = Not al all
When you think back to the trauma and the things that followed it, how upset do you feel?
0 = Not at all, 100 = Extremely
IF YOU ARE UPSET, can you describe in what way?
I relive the terror of the experience
0 = Not at all, 100 = Extremely
I feel worried that other bad things will happen to me or my family
0 = Not at all, 100 = Extremely
I feel angry
0 = Not at all, 100 = Extremely
I feel sad
0 = Not at all, 100 = Extremely
I feel guilty in some way
0 = Not at all, 100 = Extremely
I feel ashamed in some way
0 = Not at all, 100 = Extremely
I feel hopeless
0 = Not at all, 100 = Extremely
PDS
Below is a list of problems that people sometimes have after experiencing a traumatic event.  Read each one carefully and choose the answer (0-3) that best describes how often that problem has bothered you IN THE PAST WEEK AT TIMES WHEN YOU WERE NOT WITH YOUR THERAPIST OR DOING HOMEWORK. Rate each problem with respect to the traumatic events that you are receiving treatment for.
1. Having upsetting thoughts or images about the traumatic event that came into your head when you didn't want them to
0 = Not at all, 1 = Once a week or less/once in a while, 2= 2 to 4 times a week/half the time, 3 = 5 or more times a week/almost always
2. Having bad dreams or nightmares about the traumatic event
0 = Not at all, 1 = Once a week or less/once in a while, 2= 2 to 4 times a week/half the time, 3 = 5 or more times a week/almost always
3. Reliving the traumatic event, acting or feeling as if it were happening again
0 = Not at all, 1 = Once a week or less/once in a while, 2= 2 to 4 times a week/half the time, 3 = 5 or more times a week/almost always
4. Feeling emotionally upset when you were reminded of the traumatic event (for example, feeling scared, angry, sad, guilty, etc)
0 = Not at all, 1 = Once a week or less/once in a while, 2= 2 to 4 times a week/half the time, 3 = 5 or more times a week/almost always
5. Experiencing physical reactions when you were reminded of the traumatic event (for example, break into a sweat, heart beating fast)
0 = Not at all, 1 = Once a week or less/once in a while, 2= 2 to 4 times a week/half the time, 3 = 5 or more times a week/almost always
6. Trying not to think about, talk about, or have feelings about the traumatic event
0 = Not at all, 1 = Once a week or less/once in a while, 2= 2 to 4 times a week/half the time, 3 = 5 or more times a week/almost always
7. Trying to avoid activities, people or places that remind you of the traumatic event
0 = Not at all, 1 = Once a week or less/once in a while, 2= 2 to 4 times a week/half the time, 3 = 5 or more times a week/almost always
8. Not being able to remember an important part of the traumatic event
0 = Not at all, 1 = Once a week or less/once in a while, 2= 2 to 4 times a week/half the time, 3 = 5 or more times a week/almost always
9. Having much less interest participating much less often in important activities
0 = Not at all, 1 = Once a week or less/once in a while, 2= 2 to 4 times a week/half the time, 3 = 5 or more times a week/almost always
10. Feeling distant or cut off from people around you
0 = Not at all, 1 = Once a week or less/once in a while, 2= 2 to 4 times a week/half the time, 3 = 5 or more times a week/almost always
11. Feeling emotionally numb (for example being unable to cry or unable to have loving feelings)
0 = Not at all, 1 = Once a week or less/once in a while, 2= 2 to 4 times a week/half the time, 3 = 5 or more times a week/almost always
12. Feeling as if your future plans or hopes will not come true (for example, you will not have a career, marriage, children or a long life)
0 = Not at all, 1 = Once a week or less/once in a while, 2= 2 to 4 times a week/half the time, 3 = 5 or more times a week/almost always
13. Having trouble falling or staying asleep
0 = Not at all, 1 = Once a week or less/once in a while, 2= 2 to 4 times a week/half the time, 3 = 5 or more times a week/almost always
14. Feeling irritable or having fits of anger
0 = Not at all, 1 = Once a week or less/once in a while, 2= 2 to 4 times a week/half the time, 3 = 5 or more times a week/almost always
15. Having trouble concentrating (for example, drifting in and out of conversations, losing track of a story on television, forgetting what you read)
0 = Not at all, 1 = Once a week or less/once in a while, 2= 2 to 4 times a week/half the time, 3 = 5 or more times a week/almost always
16. Being overly alert, for example, checking to see who is around you, being uncomfortable with your back to a door, etc)
0 = Not at all, 1 = Once a week or less/once in a while, 2= 2 to 4 times a week/half the time, 3 = 5 or more times a week/almost always
17. Being jumpy or easily startled (for example, when someone walks up behind you)
0 = Not at all, 1 = Once a week or less/once in a while, 2= 2 to 4 times a week/half the time, 3 = 5 or more times a week/almost always