COMPREHENSIVE PRE-CLASS SURVEY

The following questions ask how you feel about your quality of life, health, or other areas of your life. Please choose the answer that appears most appropriate. If you are unsure about which response to give to a question, the first response you think of is often the best one. We ask that you think about your life in the last four weeks.

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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	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

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* 7. How would you rate your overall quality of life?

Very Poor

Poor

Neither Poor Nor Good

Good

Very Good

Very Poor

Poor

Neither Poor Nor Good

Good

Very Good

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* 8. How satisfied are you with your overall health?

Very Dissatisfied

Dissatisfied

Neither Dissatisfied Nor Satisfied

Satisfied

Very Satisfied

Very Dissatisfied

Dissatisfied

Neither Dissatisfied Nor Satisfied

Satisfied

Very Satisfied

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* 9. How much do you need medications to function in your daily life?

Not At All

A Little

A Moderate Amount

Very Much

An Extreme Amount

Not At All

A Little

A Moderate Amount

Very Much

An Extreme Amount

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* 10. The following questions ask about how much you have experienced certain things in the last four weeks.

	Not at All	A Little	A Moderate Amount	Very Much	Extremely/An Extreme Amount
How much do you enjoy life?	How much do you enjoy life? Not at All	How much do you enjoy life? A Little	How much do you enjoy life? A Moderate Amount	How much do you enjoy life? Very Much	How much do you enjoy life? Extremely/An Extreme Amount
To what extent do you feel your life to be meaningful?	To what extent do you feel your life to be meaningful? Not at All	To what extent do you feel your life to be meaningful? A Little	To what extent do you feel your life to be meaningful? A Moderate Amount	To what extent do you feel your life to be meaningful? Very Much	To what extent do you feel your life to be meaningful? Extremely/An Extreme Amount
How well are you able to concentrate?	How well are you able to concentrate? Not at All	How well are you able to concentrate? A Little	How well are you able to concentrate? A Moderate Amount	How well are you able to concentrate? Very Much	How well are you able to concentrate? Extremely/An Extreme Amount
How safe do you feel in your daily life?	How safe do you feel in your daily life? Not at All	How safe do you feel in your daily life? A Little	How safe do you feel in your daily life? A Moderate Amount	How safe do you feel in your daily life? Very Much	How safe do you feel in your daily life? Extremely/An Extreme Amount
How healthy is your physical environment?	How healthy is your physical environment? Not at All	How healthy is your physical environment? A Little	How healthy is your physical environment? A Moderate Amount	How healthy is your physical environment? Very Much	How healthy is your physical environment? Extremely/An Extreme Amount

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* 11. The following questions ask about how completely you experience or were able to do certain things in the last four weeks.

	Not At All	A Little	Moderately	Mostly	Completely
Do you have enough energy for everyday life?	Do you have enough energy for everyday life? Not At All	Do you have enough energy for everyday life? A Little	Do you have enough energy for everyday life? Moderately	Do you have enough energy for everyday life? Mostly	Do you have enough energy for everyday life? Completely
Are you able to accept your bodily appearance?	Are you able to accept your bodily appearance? Not At All	Are you able to accept your bodily appearance? A Little	Are you able to accept your bodily appearance? Moderately	Are you able to accept your bodily appearance? Mostly	Are you able to accept your bodily appearance? Completely
Have you enough money to meet your needs?	Have you enough money to meet your needs? Not At All	Have you enough money to meet your needs? A Little	Have you enough money to meet your needs? Moderately	Have you enough money to meet your needs? Mostly	Have you enough money to meet your needs? Completely
How available to you is the information that you need in your day-to-day life?	How available to you is the information that you need in your day-to-day life? Not At All	How available to you is the information that you need in your day-to-day life? A Little	How available to you is the information that you need in your day-to-day life? Moderately	How available to you is the information that you need in your day-to-day life? Mostly	How available to you is the information that you need in your day-to-day life? Completely
To what extent do you have the opportunity for leisure activities?	To what extent do you have the opportunity for leisure activities? Not At All	To what extent do you have the opportunity for leisure activities? A Little	To what extent do you have the opportunity for leisure activities? Moderately	To what extent do you have the opportunity for leisure activities? Mostly	To what extent do you have the opportunity for leisure activities? Completely

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* 12. How well are you able to get around?

Very Poorly

Poorly

Neither Poorly Nor Well

Well

Very Well

Very Poorly

Poorly

Neither Poorly Nor Well

Well

Very Well

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* 13. The following questions ask about how completely you experience or were able to do certain things in the last four weeks.

	Very Dissatisfied	Dissatisfied	Neither Dissatisfied Nor Satisfied	Satisfied	Very Satisfied
How satisfied are you with your sleep?	How satisfied are you with your sleep? Very Dissatisfied	How satisfied are you with your sleep? Dissatisfied	How satisfied are you with your sleep? Neither Dissatisfied Nor Satisfied	How satisfied are you with your sleep? Satisfied	How satisfied are you with your sleep? Very Satisfied
How satisfied are you with your ability to perform your daily living activities?	How satisfied are you with your ability to perform your daily living activities? Very Dissatisfied	How satisfied are you with your ability to perform your daily living activities? Dissatisfied	How satisfied are you with your ability to perform your daily living activities? Neither Dissatisfied Nor Satisfied	How satisfied are you with your ability to perform your daily living activities? Satisfied	How satisfied are you with your ability to perform your daily living activities? Very Satisfied
How satisfied are you with your capacity for work?	How satisfied are you with your capacity for work? Very Dissatisfied	How satisfied are you with your capacity for work? Dissatisfied	How satisfied are you with your capacity for work? Neither Dissatisfied Nor Satisfied	How satisfied are you with your capacity for work? Satisfied	How satisfied are you with your capacity for work? Very Satisfied
How satisfied are you with yourself?	How satisfied are you with yourself? Very Dissatisfied	How satisfied are you with yourself? Dissatisfied	How satisfied are you with yourself? Neither Dissatisfied Nor Satisfied	How satisfied are you with yourself? Satisfied	How satisfied are you with yourself? Very Satisfied
How satisfied are you with your personal relationships?	How satisfied are you with your personal relationships? Very Dissatisfied	How satisfied are you with your personal relationships? Dissatisfied	How satisfied are you with your personal relationships? Neither Dissatisfied Nor Satisfied	How satisfied are you with your personal relationships? Satisfied	How satisfied are you with your personal relationships? Very Satisfied
How satisfied are you with the support you get from your friends/family?	How satisfied are you with the support you get from your friends/family? Very Dissatisfied	How satisfied are you with the support you get from your friends/family? Dissatisfied	How satisfied are you with the support you get from your friends/family? Neither Dissatisfied Nor Satisfied	How satisfied are you with the support you get from your friends/family? Satisfied	How satisfied are you with the support you get from your friends/family? Very Satisfied
How satisfied are you with the conditions of your living place?	How satisfied are you with the conditions of your living place? Very Dissatisfied	How satisfied are you with the conditions of your living place? Dissatisfied	How satisfied are you with the conditions of your living place? Neither Dissatisfied Nor Satisfied	How satisfied are you with the conditions of your living place? Satisfied	How satisfied are you with the conditions of your living place? Very Satisfied
How satisfied are you with your access to quality health services?	How satisfied are you with your access to quality health services? Very Dissatisfied	How satisfied are you with your access to quality health services? Dissatisfied	How satisfied are you with your access to quality health services? Neither Dissatisfied Nor Satisfied	How satisfied are you with your access to quality health services? Satisfied	How satisfied are you with your access to quality health services? Very Satisfied
How satisfied are you with your transportation?	How satisfied are you with your transportation? Very Dissatisfied	How satisfied are you with your transportation? Dissatisfied	How satisfied are you with your transportation? Neither Dissatisfied Nor Satisfied	How satisfied are you with your transportation? Satisfied	How satisfied are you with your transportation? Very Satisfied

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* 14. How often do you have negative feelings such as blue mood, despair, anxiety, depression?

Never

Seldom

Quite Often

Very Often

Always

Never

Seldom

Quite Often

Very Often

Always