PRE-CLASS SYMPTOM SURVEY

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* 1. Please enter your first name.

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* 2. Please enter your last name.

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* 3. Please enter your date of birth.

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* 4. Please indicate how often you have experienced each of the following in the last thirty (30) days:

	Not at All	A Little Bit	Moderately	Quite a Bit	Almost Always
Disturbing memories, thoughts, or images of past trauma	Disturbing memories, thoughts, or images of past trauma Not at All	Disturbing memories, thoughts, or images of past trauma A Little Bit	Disturbing memories, thoughts, or images of past trauma Moderately	Disturbing memories, thoughts, or images of past trauma Quite a Bit	Disturbing memories, thoughts, or images of past trauma Almost Always
Bad dreams or nightmares related to past trauma	Bad dreams or nightmares related to past trauma Not at All	Bad dreams or nightmares related to past trauma A Little Bit	Bad dreams or nightmares related to past trauma Moderately	Bad dreams or nightmares related to past trauma Quite a Bit	Bad dreams or nightmares related to past trauma Almost Always
Feeling upset when reminded of past traumatic experiences	Feeling upset when reminded of past traumatic experiences Not at All	Feeling upset when reminded of past traumatic experiences A Little Bit	Feeling upset when reminded of past traumatic experiences Moderately	Feeling upset when reminded of past traumatic experiences Quite a Bit	Feeling upset when reminded of past traumatic experiences Almost Always
Experiencing physical symptoms when reminded of past traumatic experiences (I.e. sweating, heart racing, trouble breathing, etc.)	Experiencing physical symptoms when reminded of past traumatic experiences (I.e. sweating, heart racing, trouble breathing, etc.) Not at All	Experiencing physical symptoms when reminded of past traumatic experiences (I.e. sweating, heart racing, trouble breathing, etc.) A Little Bit	Experiencing physical symptoms when reminded of past traumatic experiences (I.e. sweating, heart racing, trouble breathing, etc.) Moderately	Experiencing physical symptoms when reminded of past traumatic experiences (I.e. sweating, heart racing, trouble breathing, etc.) Quite a Bit	Experiencing physical symptoms when reminded of past traumatic experiences (I.e. sweating, heart racing, trouble breathing, etc.) Almost Always
Actively avoiding thinking about or talking about past trauma	Actively avoiding thinking about or talking about past trauma Not at All	Actively avoiding thinking about or talking about past trauma A Little Bit	Actively avoiding thinking about or talking about past trauma Moderately	Actively avoiding thinking about or talking about past trauma Quite a Bit	Actively avoiding thinking about or talking about past trauma Almost Always
Trouble remembering traumatic experiences	Trouble remembering traumatic experiences Not at All	Trouble remembering traumatic experiences A Little Bit	Trouble remembering traumatic experiences Moderately	Trouble remembering traumatic experiences Quite a Bit	Trouble remembering traumatic experiences Almost Always
Having strong negative beliefs about yourself, other people, or the world (I.e. “there is something wrong with me,” or, “nobody understands what I am feeling,” or, “others can’t be trusted”)	Having strong negative beliefs about yourself, other people, or the world (I.e. “there is something wrong with me,” or, “nobody understands what I am feeling,” or, “others can’t be trusted”) Not at All	Having strong negative beliefs about yourself, other people, or the world (I.e. “there is something wrong with me,” or, “nobody understands what I am feeling,” or, “others can’t be trusted”) A Little Bit	Having strong negative beliefs about yourself, other people, or the world (I.e. “there is something wrong with me,” or, “nobody understands what I am feeling,” or, “others can’t be trusted”) Moderately	Having strong negative beliefs about yourself, other people, or the world (I.e. “there is something wrong with me,” or, “nobody understands what I am feeling,” or, “others can’t be trusted”) Quite a Bit	Having strong negative beliefs about yourself, other people, or the world (I.e. “there is something wrong with me,” or, “nobody understands what I am feeling,” or, “others can’t be trusted”) Almost Always
Blaming yourself for traumatic experiences or what happened after	Blaming yourself for traumatic experiences or what happened after Not at All	Blaming yourself for traumatic experiences or what happened after A Little Bit	Blaming yourself for traumatic experiences or what happened after Moderately	Blaming yourself for traumatic experiences or what happened after Quite a Bit	Blaming yourself for traumatic experiences or what happened after Almost Always
Feeling negative emotions, such as fear, anger, guilt, or shame	Feeling negative emotions, such as fear, anger, guilt, or shame Not at All	Feeling negative emotions, such as fear, anger, guilt, or shame A Little Bit	Feeling negative emotions, such as fear, anger, guilt, or shame Moderately	Feeling negative emotions, such as fear, anger, guilt, or shame Quite a Bit	Feeling negative emotions, such as fear, anger, guilt, or shame Almost Always
Loss of interest in things that you used to enjoy	Loss of interest in things that you used to enjoy Not at All	Loss of interest in things that you used to enjoy A Little Bit	Loss of interest in things that you used to enjoy Moderately	Loss of interest in things that you used to enjoy Quite a Bit	Loss of interest in things that you used to enjoy Almost Always
Feeling distant or cut off from other people	Feeling distant or cut off from other people Not at All	Feeling distant or cut off from other people A Little Bit	Feeling distant or cut off from other people Moderately	Feeling distant or cut off from other people Quite a Bit	Feeling distant or cut off from other people Almost Always
Feeling emotionally numb, or feeling unable to have loving feelings for those close to you	Feeling emotionally numb, or feeling unable to have loving feelings for those close to you Not at All	Feeling emotionally numb, or feeling unable to have loving feelings for those close to you A Little Bit	Feeling emotionally numb, or feeling unable to have loving feelings for those close to you Moderately	Feeling emotionally numb, or feeling unable to have loving feelings for those close to you Quite a Bit	Feeling emotionally numb, or feeling unable to have loving feelings for those close to you Almost Always
Feeling as if your future hopes or plans will not come true	Feeling as if your future hopes or plans will not come true Not at All	Feeling as if your future hopes or plans will not come true A Little Bit	Feeling as if your future hopes or plans will not come true Moderately	Feeling as if your future hopes or plans will not come true Quite a Bit	Feeling as if your future hopes or plans will not come true Almost Always
Trouble falling or staying asleep	Trouble falling or staying asleep Not at All	Trouble falling or staying asleep A Little Bit	Trouble falling or staying asleep Moderately	Trouble falling or staying asleep Quite a Bit	Trouble falling or staying asleep Almost Always
Feeling irritable or having angry outbursts	Feeling irritable or having angry outbursts Not at All	Feeling irritable or having angry outbursts A Little Bit	Feeling irritable or having angry outbursts Moderately	Feeling irritable or having angry outbursts Quite a Bit	Feeling irritable or having angry outbursts Almost Always
Having difficulty concentrating	Having difficulty concentrating Not at All	Having difficulty concentrating A Little Bit	Having difficulty concentrating Moderately	Having difficulty concentrating Quite a Bit	Having difficulty concentrating Almost Always
Being super alert or watchful/on guard	Being super alert or watchful/on guard Not at All	Being super alert or watchful/on guard A Little Bit	Being super alert or watchful/on guard Moderately	Being super alert or watchful/on guard Quite a Bit	Being super alert or watchful/on guard Almost Always
Feeling jumpy or being easily startled	Feeling jumpy or being easily startled Not at All	Feeling jumpy or being easily startled A Little Bit	Feeling jumpy or being easily startled Moderately	Feeling jumpy or being easily startled Quite a Bit	Feeling jumpy or being easily startled Almost Always
Trouble experiencing positive emotions, such as happiness, hopefulness, or trust	Trouble experiencing positive emotions, such as happiness, hopefulness, or trust Not at All	Trouble experiencing positive emotions, such as happiness, hopefulness, or trust A Little Bit	Trouble experiencing positive emotions, such as happiness, hopefulness, or trust Moderately	Trouble experiencing positive emotions, such as happiness, hopefulness, or trust Quite a Bit	Trouble experiencing positive emotions, such as happiness, hopefulness, or trust Almost Always
Taking risks or doing things that could cause you harm	Taking risks or doing things that could cause you harm Not at All	Taking risks or doing things that could cause you harm A Little Bit	Taking risks or doing things that could cause you harm Moderately	Taking risks or doing things that could cause you harm Quite a Bit	Taking risks or doing things that could cause you harm Almost Always
Feeling as if things would be better if you weren’t alive	Feeling as if things would be better if you weren’t alive Not at All	Feeling as if things would be better if you weren’t alive A Little Bit	Feeling as if things would be better if you weren’t alive Moderately	Feeling as if things would be better if you weren’t alive Quite a Bit	Feeling as if things would be better if you weren’t alive Almost Always

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* 5. Please check all of the symptoms you have experienced during the last 4 weeks.

Depression/Sadness

Anxiety

Insomnia

Flashbacks/Nightmares

Hyper-vigilance/Paranoia

Hyper-arousal/Trouble Concentrating

Agitation/Irritability

Loss of Interest or Pleasure in Activities

Lethargy/Sleeping Too Much

Memory Problems

None of these symptoms

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* 6. How much do the symptoms from the previous question negatively impact the following areas of your life?

	Not at All	A Little Bit	Somewhat	Quite a Bit	Extremely	N/A
Job or School	Job or School Not at All	Job or School A Little Bit	Job or School Somewhat	Job or School Quite a Bit	Job or School Extremely	Job or School N/A
Physical Health	Physical Health Not at All	Physical Health A Little Bit	Physical Health Somewhat	Physical Health Quite a Bit	Physical Health Extremely	Physical Health N/A
Household Duties	Household Duties Not at All	Household Duties A Little Bit	Household Duties Somewhat	Household Duties Quite a Bit	Household Duties Extremely	Household Duties N/A
Friendships	Friendships Not at All	Friendships A Little Bit	Friendships Somewhat	Friendships Quite a Bit	Friendships Extremely	Friendships N/A
Fun/Leisure Activities	Fun/Leisure Activities Not at All	Fun/Leisure Activities A Little Bit	Fun/Leisure Activities Somewhat	Fun/Leisure Activities Quite a Bit	Fun/Leisure Activities Extremely	Fun/Leisure Activities N/A
Self-Care	Self-Care Not at All	Self-Care A Little Bit	Self-Care Somewhat	Self-Care Quite a Bit	Self-Care Extremely	Self-Care N/A
Relationships	Relationships Not at All	Relationships A Little Bit	Relationships Somewhat	Relationships Quite a Bit	Relationships Extremely	Relationships N/A
General Life Satisfaction	General Life Satisfaction Not at All	General Life Satisfaction A Little Bit	General Life Satisfaction Somewhat	General Life Satisfaction Quite a Bit	General Life Satisfaction Extremely	General Life Satisfaction N/A