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Psychology/Post Trauma Stress Assessment
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Post-Traumatic Stress Assessment
Date: ___________________
Client Name:_____________________
Trauma: ________________________ Date of 1st Instance: ____________________________
Since the trauma, which of the following is being experienced, and how frequently?
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| * Intrusive thoughts and images
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| * Recurring dreams, nightmares
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| * Flashbacks
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| * Anxiety attacks
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| * Crying spells and tearfulness
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| * Feelings of shame, embarrassment
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| * Guild Feelings (“If only...”)
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| * Withdrawal
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| * Depression – diminished interest
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| * Feeling of detachment or estrangement
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| * Inability to recall specific events of trauma
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| * Disorientation, confusion
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| * Restricted effect
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| * Avoidance of thoughts of trauma
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| * Fear
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| * Job difficulties
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| * Family, interpersonal difficulties
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| * Sexual dysfunction
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| * Numbness – emotional / physical
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| * Helplessness, loss of control
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| * Sleep disturbances
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| * Anger / Rage
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| * Difficulty in concentrating
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| * Hypervigilance
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| * High startle response
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| * Headaches
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| * Muscle tension
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| * Nausea
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| * Eating disturbances
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| * Difficulty in breathing
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| * Cold sweat
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| * Increased use of alcohol
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| * Increased use of drugs
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Presently taking medication? Yes: _______ No: _________Explain: _________________________________________________________
Specific Health Problems:
Explain: __________________________________________________________
Doctor: __________________________________________________________
