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

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

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

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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?
To what extent do you feel your life to be meaningful?
How well are you able to concentrate?
How safe do you feel in your daily life?
How healthy is your physical environment?

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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?
Are you able to accept your bodily appearance?
Have you enough money to meet your needs?
How available to you is the information that you need in your day-to-day life?
To what extent do you have the opportunity for leisure activities?

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

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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 ability to perform your daily living activities?
How satisfied are you with your capacity for work?
How satisfied are you with yourself?
How satisfied are you with your personal relationships?
How satisfied are you with the support you get from your friends/family?
How satisfied are you with the conditions of your living place?
How satisfied are you with your access to quality health services?
How satisfied are you with your transportation?

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

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