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PTSD Screening (PTSD-5)
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Name
*
First
Last
Email
*
Phone
Date of Birth:
In the past month, have you:
Had nightmares about the event(s) or thought about the event(s) when you did not want to?
*
Select One
No
Yes
Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)?
*
Select One
No
Yes
Been constantly on guard, watchful, or easily startled?
*
Select One
No
Yes
Felt numb or detached from people, activities, or your surroundings?
*
Select One
No
Yes
Felt guilty or unable to stop blaming yourself or others for the events(s) or any problems the event(s) may have caused?
*
Select One
No
Yes
Results
Results
Results of the assessment 1
Negative for PTSD
Results of the assessment 2
Possible PTSD
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