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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.

Date

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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
Bad dreams or nightmares related to past trauma
Feeling upset when reminded of past traumatic experiences 
Experiencing physical symptoms when reminded of past traumatic experiences (I.e. sweating, heart racing, trouble breathing, etc.)
Actively avoiding thinking about or talking about past trauma 
Trouble remembering traumatic experiences 
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”)
Blaming yourself for traumatic experiences or what happened after
Feeling negative emotions, such as fear, anger, guilt, or shame
Loss of interest in things that you used to enjoy
Feeling distant or cut off from other people 
Feeling emotionally numb, or feeling unable to have loving feelings for those close to you 
Feeling as if your future hopes or plans will not come true
Trouble falling or staying asleep 
Feeling irritable or having angry outbursts 
Having difficulty concentrating 
Being super alert or watchful/on guard
Feeling jumpy or being easily startled 
Trouble experiencing positive emotions, such as happiness, hopefulness, or trust
Taking risks or doing things that could cause you harm
Feeling as if things would be better if you weren’t alive

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

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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
Physical Health
Household Duties 
Friendships 
Fun/Leisure Activities 
Self-Care
Relationships
General Life Satisfaction 
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