IRAQ WAR CLINICIAN GUIDE

Iraq War Clinician Guide 122 Appendix D
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READ THIS FIRST: Now we are going to ask you some quesfions about eve& in your life that are fightening,
upsetdng, or stmdd to most people. Please think back over your whole when you answer these quatiom
Some of these questions may be about upsetting events you don't usually talk about You answers are important,
but you do not have to answer anv questions that vou do not want to. Thankyou
1. Have you ever been in aserious disaster (for exan~ple, an
earthquake, hurricane, large tire, explosion)? YES NO
a. Haw aldwere you when thishappened?
c. At thetime oftheevent did youbelievethatyou orsomeo~reelrecouldbe Mlledor seriouslyhamredl YES NO
d. At the time afthe event did you enperieneefeelings of idsrsebe~lss~~ess./eor,orho~roR YES NO
e. Hawmuchhasthis affected your life inthopart year? (1) (2) (3) (4) (9
not rt dl some extremely
2. Have you ever seen a serious accident (for example, a bad car wreck or
an olrlhe-job accident)? YES NO
a How old were you when thir happened?
c. A1 the time aftheevent did youbelieve thatyou orsomeone &ecouldbekllledor se"ourlyharmedl YES NO
d. At the lime of the event did you experience feelings of inlmsr he~I~snr~s,/eor,orhorro,l YES NO
e. How muchbs this affected your life in the past ye=? (1) @I (3) (4) (5)
oat at all some extremely
3. Have you ever had a very serious accident or accident-related injury
(for example, a bad car wreck or an on-ale-job accident)? YES NO
a HOWold were YOU when thishppenem -
c. At thelime ofthe event did youbelievethnryoa orsomeoneelsecouldbe Mlledor seriously bmmcd? YES NO
d At the lime ofthe event did youexp~riencefcelings of i~let~ebe~lers~~~s,/eor,
oriiorrofl YES NO
e. How muchhas thisaffected your life inthepast year? (1) (2) (3) (4) (5)
not at dl some extremely
4. Was a close family member ever sent to jail? YES NO
a How oldwere you whenlhishappened? --- b. When it ended?
e. How muchhar this affected you life inthe past year? (1) (2) (3) (4) (5)
not nt dl some extremely
5. Have you ever been sent to jail? YES NO
a How old were you when lhi~happened? -- [ b. When it ended?
I
e. How muchhas this affechd yaw life inthe past year? (1) (2) 3 (4) (5)
not atdl raw extremely
6. Were you ever put in foster care or put up for adoption? YES NO
a. Haw aldwere you when thishappened? - b. Whenit ended?
e. Haw much has lh'i affected your lifein the past y d (1) (2) 3 (4 (5)
not st dl some extremely
7. Did your parents ever separate or divorce while you were
livingmth them? YES NO
a. Now old were you hen
thir happenem
b. When it ended?
r. Haw much has this affected your life in the past y d (1) (2) 3 (4) (5)
not at dl some ertremely
8. Have you ever been separated or divorced? YES NO
a. How old were you when thisllappened? -- b. When it en&&
e. Haw muchhar this affected your life in the past year? (1) (2) (3) (4) (5)
oat at dl same ertremely
9. Have you ever had serious money problenls (for example, not enough
nloney for food or place to live)? YES NO
a. How old were you when this happened? b. When it ended?-
e. How much has this affected your life in the past year? (1) (2) (3) (4) (5)
not at dl some extremely
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DEPARTMENT OF VETERANS AFFAIRS
NATIONAL CENTER FOR PTSD