Please answer the following four questions.
- Have you survived a trauma in which you experienced an event
outside of your control that involved a physical threat?
Yes No
- Have you survived a
trauma in which you witnessed an event outside of your control
that involved a physical threat to someone else?
Yes No
- If you answered yes to
both Questions 1 and 2, please indicate the trauma that has affected
you the most.
physical threat to
yourself physical
threat to someone else
not applicable (no to both questions)
Please answer the
following question as it relates to the trauma that has affected
(upset) you the most.
- Did your response to
the trauma involve intense helplessness, fear, or horror?
Yes No
Below is a list of problems and complaints that active military
and veterans sometimes have in response to stressful life experiences.
Please read each one carefully and indicate how much you have been
bothered by that problem in the last month.
| |
Not at all
|
A little bit
|
Moderately
|
Quite a
bit
|
Extremely |
| 5. Repeated, disturbing
memories, thoughts, or images of a stressful military experience
from the past? |
|
|
| |
|
| 6. Repeated, disturbing memories, thoughts, or images of
harm occurring to another person? |
|
|
| |
|
| 7.
Repeated, disturbing dreams of a stressful military experience
from the past? |
|
|
| |
|
| 8. Suddenly acting or feeling as if a stressful
military experience were happening again (as if you were reliving
it)? |
| |
| |
|
| 9. Feeling
very upset when something reminded you of a stressful
military experience from the past?
|
| |
|
|
|
| 10. Having physical reactions (e.g., heart pounding,
trouble breathing, or sweating) when something reminded you of a
stressful military experience from the past?
|
| |
|
|
|
| 11. Avoid
thinking about or talking about a stressful military
experience from the past or avoid having feelings related to
it?
|
| |
|
|
|
| 12. Avoid activities or situations because they
remind you of a stressful military experience from the
past?
|
| |
|
|
|
| 13. Trouble
remembering important parts of a stressful military experience
from the past?
|
| |
|
|
|
| |
Not at all
|
A little bit
|
Moderately
|
Quite a bit
|
Extremely
|
| 14. Loss of
interest in things that you used to enjoy? |
| |
| |
|
| 15. Feeling distant or cut off from other
people? |
| |
| |
|
| 16. Feeling
emotionally numb or being unable to have loving feelings for
those close to you? |
| |
| |
|
| 17. Feeling as if your future will somehow be cut
short?
|
| |
|
|
|
| 18. Trouble
falling or staying asleep?
|
| |
|
|
|
| 19. Feeling irritable or having angry
outbursts?
|
| |
|
|
|
| 20. Having
difficulty concentrating? |
| |
| |
|
| 21. Being "super alert" or watchful on guard?
|
| |
| |
|
| 22. Feeling
jumpy or easily startled? |
| |
| |
|
IGQ (© O'Connor
& Berry)
These are questions about your emotions. Please
answer using the 1 to 5 response scale indicated.
CESD
Select the answer that best describes your situation
over the past week.
SLS
Below are five statements that you may agree or
disagree with. Using the 1 - 7 scale below indicate your agreement with
each item by placing the appropriate number on the line preceding that
item. Please be open and honest in your responding.
General Information
How did you hear about this study?
listserve
link from an online social networking site or another
webiste:
craigslist city:
web search
from a
friend
Other
Age
Gender
Female Male Transgender
What ethnic/racial/cultural, and/or national background do you most
identify with?
In what country did you spend most of your youth?
How would you describe the area where you grew up?
If other, please describe:
How long did you live there? (in years)
In what country do you currently live?
How would you describe the area where you currently live?
If other, please
describe:
How long have you lived there? (In years)
Where would you place your parents on the following spectrum for
social class?
If financially independent, where would you place yourself on the
following spectrum for social class? If you are not financially
independent, please select the 'Not financially independent' option.
What is the highest level of formal education your mother or father
(whichever is the highest) has completed?
What is the highest level of formal education you have completed?
What is your religious background, i.e. what religion did you grow up
with?
Which religion do you identify with currently?
What is your current relationship status? (please check the one that
applies best to you)
If you have children, indicate how many.
Do you plan to have children in the future?
Yes No