PTSD Checklist - Homecoming For Veterans
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- Ronald Fletcher
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1 PTSD Checklist - Homecoming For Veterans New Client Evaluation/PTSD Pilot Program Client s Name: Facility: Clinician: Date: Instruction to client: Below is a list of common problems and complaints that are related to stressful military experiences. Please read each one carefully, put an X in the box to indicate how much you have been bothered by that problem in the last month.. Response: t at all (1) A little bit (2) Moderately (3) Quite a bit (4) Extremely (5) 1. Repeated, disturbing memories, thoughts, or images of a stressful military experience? 2. Repeated, disturbing dreams of a stressful military experience? Suddenly acting or feeling as if a stressful military experience were happening again (as if you were reliving it)? Feeling very upset when something reminded you of a stressful military experience? Having physical reactions (e.g., heart pounding, trouble breathing, or sweating) when something reminded you of a stressful military experience? Avoid thinking about or talking about a stressful military experience or avoid having feelings related to it? 7. Avoid activities or situations because they remind you of a stressful military experience? 8. Trouble remembering important parts of a stressful military experience? 9. Loss of interest in things that you used to enjoy? 10. Feeling distant or cut off from other people? 11. Feeling emotionally numb or being unable to have loving feelings for those close to you? 12. Feeling as if your future will somehow be cut short? 13. Trouble falling or staying asleep? 14. Feeling irritable or having angry outbursts? 15. Having difficulty concentrating? 16. Being super alert or watchful on guard? 17. Feeling jumpy or easily startled? Page 1 of 1
2 INTAKE FORM Identifying Information Name: Date: Gender: male female SSN: (last 4) Marital Status: single married separated Age: divorced widowed other: Ethnicity: Caucasian African-American Hispanic/Latino Native American Asian/Pacific Islander Other: Contact Phone#: Work Phone#: Living with: wife/significant other roommate offspring(#: ) alone Rank/Rate: Branch of Service: USMC USN Army USAF Duty Station: Unit: Time in Service: years months continuous service broken service EAS date (month/year): Deployments: Dates (mo/yr to mo/yr) Location: 1) to 2) to 3) to 4) to 5) to Mental Health History Chief/Current Complaint: 1. Who referred you? 2. What brings you in today? Page 1 of 5
3 Mental Health History (cont.) Ever had any: Prior mental health therapy/counseling? Prior psychiatric medications? Prior psychiatric hospitalizations? Why? Why? Why? Please list past psych meds: Prior mental health/psychiatric diagnoses given: Any current psychiatric medications or therapy/counseling: Biological family history of mental health diagnosis or treatment? Don t Know Who (relationship)? Diagnosis Treatment (check all that apply): In the past, have you ever: Thought of suicide? Attempted suicide? How? Thought of killing someone else? (non-combat situation) Tried to kill someone else? (non-combat situation) Who? Who? How? Engaged in self-injury (cutting, burning yourself, etc.) Are you now: Thinking of hurting yourself? Thinking of hurting someone else? How? How? Thinking of cutting/burning yourself? What stops you from acting on thoughts of hurting others of yourself? Current Physical Problems/Medical Conditions (please list): History of Head Injury? Medication Allergies? History of Seizures? If yes, to what? History of Blackouts? Problems with dizziness now? Page 2 of 5
4 Current Physical Problems/Medical Conditions (cont.) Problems with headaches now? Problems with ringing in ears now? Current physical pain rating: from 0 (none) to 10 (excrutiating) = of 10 Current medications: Sleep problems? (circle) trouble getting to sleep waking up at night oversleeping waking too early in the morning excessive snoring naps during the day bothered by nightmares vivid dreams restless legs Eating problems? (circle) overeating loss of appetite binging&purging Weight change in past month? ne Gain Loss of lb. Substance Use Current number of times using alcohol per week: Current number of drinks per occasion: Past evaluation or treatment for alcohol abuse? Type: evaluation only inpatient/residential outpatient alcohol awareness classes Ever had alcohol-related ticket/arrest/dui? Current illicit drug use: Past illicit drug use: Family alcohol/drug history? What? What? Who? Social History Early Development: Born where? Rasied where? Number of brothers: Number of sisters: Number of half/step-siblings: Home discipline/enforcement of rules: strict lenient inconsistent absent Raised by: biological parents mother&stepfather father&stepmother grandparents foster care adoptive parents single parent institution How would you describe your childhood? Exposure to Trauma/Abuse/Neglect: Emotional/psychological abuse: unsure How old were you? Physical abuse: Sexual abuse/molestation Neglect/abandonment: unsure unsure unsure Page 3 of 5
5 Social History (cont.) Witnessing Domestic Violence Deaths in the Family Out-of-home placement / homelessness unsure unsure unsure School History: Ever need special education services? Ever tested for a learning disability? Ever tested for ADHD? Ever expelled from school? What for? Results: Results: Why? # Out-of-school suspensions in middle and high school: Reasons for suspensions: (check all that apply) fighting destroying property defiance alcohol/drugs skipping school disrupting class Educational level: did not finish high school high school diploma GED some college credits AA degree bachelor s degree other: Legal History: Ever arrested/cited as a juvenile? Ever adjudicated delinquent? Ever arrested/cited as an adult? Ever convicted as an adult? What for? What for? What for? What for? Consequence: Jail/Prison Fine Community Service Restitution Probation/Parole Military Disciplinary Consequences: NJP: Page 11 Counseling Sheets Captain s Masts Court Martial Restriction Loss of Pay Reduction in Rank MPO Confinement in Brig Reason: Page 4 of 5
6 HPI: (check any that apply) Problems with: Mood Behavior Thinking/Attitude Relationships Stress For how long? days/weeks/months/years Possibly started/triggered by: (please circle which of the following apply): Mood: sad angry happy numb afraid ashamed confused silly irritated worried on edge moody don t care bored Behavior: fighting breaking things irresponsible impulsive withdrawn unpredictable odd habits/rituals work problems jumpy thrill-seeking Thinking/Attitude: Relationships: negative confused constant worrying too distracted unmotivated guilty hopeless distrustful suspicious conflicts separation unfaithfulness parenting problems jealousy domestic violence grief/loss isolation don t care arguing Current Stressors: (check which apply) family friends finances school deaths/losses lifestyle changes relatives significant other health problems work separation other: What else should we know about you and what would be most helpful for you today? Thank you for taking the time to complete this form. Please return this to your provider. Page 5 of 5
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507 N Davis Drive Suite 1A Warner Robins, GA Phone: (478) Fax: (478)
Office Use Only Client # Ins. Dx: Need Monthly Statement? Yes No EAP Yes No Individual Family Today s Date: GENERAL INFORMATION Please print Client Name: Last First: MI: Mailing Address: City: State: Zip:
PATIENT SURVEY FOR ADMINISTRATIVE USE ONLY. TO BE COMPLETED BY STUDY COORDINATOR.
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Height: Weight: Neck Size: Does your work involve shift work? Yes No. Where did you hear about us: Physician Media Friend Other
Personal Information Name: Date of birth: Sex: Male Female Marital Status: Nationality: MRN(for KAUH Patients): Height: Weight: Neck Size: Address: Occupation: Length of work day: Does your work involve
CLIENT HISTORY CLIENT LEGAL NAME: CLIENT PREFERRED NAME:
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Nebraska Bariatric Medicine 8207 Northwoods Dr., Suite 101 Lincoln, NE MEDICAL HISTORY
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PHONE: RELATIONSHIP: ADDRESS:
Les Fehmi, Ph.D. 317 Mt. Lucas Road Princeton NJ 08540 609.924.0782 Fax: 609.924.0782 lesfehmi@openfocus.com www.openfocus.com Date: Interviewer: Referred By: 1. NAME: MALE/FEMALE BIRTH DATE: / / 2. ADDRESS:
5975 Parkway North Blvd., Suite D 3060 Royal Blvd. South, Suite 110 Cumming, GA Alpharetta, GA 30022
1 5975 Parkway North Blvd., Suite D 3060 Royal Blvd. South, Suite 110 Cumming, GA 30040 Alpharetta, GA 30022 (p) 404-388-3909 www.focusforwardcc.com (f) 678-712-1945 info@focusforwardcc.com ADULT HISTORY
GENERAL BEHAVIOR INVENTORY Self-Report Version Never or Sometimes Often Very Often
GENERAL BEHAVIOR INVENTORY Self-Report Version Here are some questions about behaviors that occur in the general population. Think about how often they occur for you. Using the scale below, select the
1811 B Green Circle Valdosta, GA Do you have any problems at this time?
TVC 1811 B Green Circle Valdosta, GA 31602 229-244-9688 Name: Date: Do you have any problems at this time? Please check any symptoms that describe how you feel, think, or behave currently or during the
Name: Date: Who referred you? Current Psychiatrist: Clinical Information:
LIFE HISTORY QUESTIONNAIRE Adult The purpose of this questionnaire is to obtain an understanding of your life experience and background. Then we can begin to develop a comprehensive treatment program suited