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PTSD Diagnosis Guide

This form is a Post Traumatic Stress Disorder (PTSD) Diagnosis tool, however; this tool by no means constitutes a diagnosis of PostTraumatic Stress Disorder. This form acts as a guide only in which you may use to discuss with your psychiatrist or physician.

How To Use The PTSD Diagnosis

Read each question, and choose what is, and is not, applicable to the way in which you feel upon your worst day, and not how you feel at present. Your first answer is often your correct answer. Don't over think or reread once answered.

The information within this form IS documented for statistical purposes, however; NO personal identification is stored, including IP or location. There are no names, email or personally identifiable information required, or saved from using this form. It is confidential and processes securely.

To achieve best results, have a spouse or family member assist you in filling out this form, as they often know more about your reactions and symptom analysis than you the sufferer do.

You must select an option in every area, or else you will force calculation errors on the summary sheet. Simply use your back button if that occurs, make selection of any part you missed.

Read each question, then place your mouse pointer over the question to view more information, examples and general help in answering each question.

Pre-Requisites

Did you experience, witness, or were confronted with an event/s that involved actual or threatened death, serious injury, or a threat to the physical integrity of yourself or others?

Yes No

Did your response involve intense fear, helplessness, or horror?
Note: In children, this may be expressed instead by disorganized or agitated behaviour.

Yes No

Re-Experiencing Symptoms

Do you have recurrent, intrusive and distressing recollections of the event, including images, thoughts, or perceptions?
Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.

Yes No

(Select Level of Intensity) Zero Extreme

Do you have recurrent distressing dreams of the event?
Note: In children, there may be frightening dreams without recognizable content.

Yes No

(Select Level of Intensity) Zero Extreme

Do you act or feel as if the traumatic event were recurring? (ie. a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated)
Note: In young children, trauma-specific re-enactment may occur.

Yes No

(Select Level of Intensity) Zero Extreme

Do you have intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event? (ie. reminded of the traumatic event by triggers)

Yes No

(Select Level of Intensity) Zero Extreme

Do you have physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event? (ie. feel tense when reminded of a traumatic event)

Yes No

(Select Level of Intensity) Zero Extreme

Numbing and Avoidance Symptoms

Do you avoid thoughts, feelings, or conversations associated with the trauma?

Yes No

(Select Level of Intensity) Zero Extreme

Do you avoid activities, places, or people that arouse recollections of the trauma?

Yes No

(Select Level of Intensity) Zero Extreme

Do you have an inability to recall an important aspect of the trauma?

Yes No

(Select Level of Intensity) Zero Extreme

Do you have markedly diminished interest or participation in significant activities?

Yes No

(Select Level of Intensity) Zero Extreme

Do you have feelings of detachment or estrangement from others?

Yes No

(Select Level of Intensity) Zero Extreme

Do you have a restricted range of affect? (ie. unable to have loving feelings)

Yes No

(Select Level of Intensity) Zero Extreme

Do you have a sense of a foreshortened future? (ie. does not expect to have a career, marriage, children, or a normal life span)

Yes No

(Select Level of Intensity) Zero Extreme

Hyper-Arousal Symptoms

Do you have difficulty falling or staying asleep?

Yes No

(Select Level of Intensity) Zero Extreme

Do you have irritability or outbursts of anger?

Yes No

(Select Level of Intensity) Zero Extreme

Do you suffer difficulty concentrating?

Yes No

(Select Level of Intensity) Zero Extreme

Do you have hyper-vigilance?

Yes No

(Select Level of Intensity) Zero Extreme

Do you have an exaggerated startle response?

Yes No

(Select Level of Intensity) Zero Extreme

Social and Work Dysfunction

Do you mix socially with others outside your family?

Yes No

(Select Level of Intensity) Zero Extreme

Do you have strong family relationships?

Yes No

(Select Level of Intensity) Zero Extreme

Do you maintain a normal, healthy relationship with your partner?

Yes No

(Select Level of Intensity) Zero Extreme

Do you cope with everyday situations?

Yes No

(Select Level of Intensity) Zero Extreme

Do you cope with your employment?

Yes No

(Select Level of Intensity) Zero Extreme

Miscellaneous

How long have you had these symptoms?

Less Than One Month
One to Three Months
Four Months or Longer

In conjunction with these above factors, to be diagnosed with PTSD you must also satisfy that "the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning", which is ascertained by your psychiatrist.