PTSD – Post Traumatic Stress Disorder

Post-Traumatic Disorder Self-Test

If you suspect that you may suffer from Post-Traumatic Stress Disorder (PTSD), complete the self-test form, by clicking the link below and printing the form out. Simply circle either ‘yes’ or ‘no’ in answer to the questions. Once completed, show the results to your Doctor.

Yes/ No

Have you experienced or witnessed a life-threatening event that caused intense fear, helplessness or horror? This includes sexual abuse.

Do you re-experience the event in at least one of the following ways?

Yes No Repeated, distressing memories and/or dreams?

Yes No Acting or feeling as if the event was happening again? (flashbacks or re-living it).

Yes No Intense physical and/or emotional distress when you are exposed to things that remind you of the event?

Yes No Do you avoid reminders of the event and feel numb, compared to the way you felt before?

Yes No Do you avoid thoughts, feelings and conversations about the event?

Yes No Do you avoid activities, places or people who remind you of it?

Yes No Have you blanked on parts of the detail?

Yes No Are you losing interest in significant activities in your life?

Yes No Are you feeling detached from other people?

Yes No Do you feel as if your range of emotions is restricted?

Yes No Do you feel as if your future is diminished in terms of marriage, children or a normal life span?

Are you troubled by two or more of the following:

Yes No Problems sleeping?

Yes No Irritability or outbursts of anger?

Yes No Problems concentrating?

Yes No Feeling ‘on-guard’?

Yes No An exaggerated startle response?

Having more than one illness at the same time can make it difficult to diagnose and treat the different conditions. Illness that sometimes complicate an anxiety disorder include depression and substance abuse. With this in mind, please take a moment to answer the following:
Yes No Have you experienced changes in sleeping or eating habits?

More days than not, do you feel:

Yes No Sad or Depressed?

Yes No Disinterested in life?

Yes No Worthless or guilty?

During the last year, has the use of alcohol or drugs:

Yes No Resulted in your failure to fulfill responsibilities with work, school or family?

Yes No Placed you in a dangerous situation, such as driving a car under the influence?

Yes No Been responsible for you being arrested?

Yes No Continued despite causing problems for you and your loved ones?

Reference: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Washington DC, American Psychiatric Association.

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