IRAQ WAR CLINICIAN GUIDE

Iraq War Clinician Guide
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123 Appendix D
10. Have you ever had a very serious physical or mental illness (for exatnple,
cancer, heart attack, serious operation, felt like killing yourself, hospitalized
because of nerve problems)? YES NO
a How oldwere you when thirhappened?
b. When it ended?
c. At the time ofthe event did you believe thatyou orsomaoneeklrecouldbeKilledor seriouslyhnmtem YES NO
d. At the time of the event did youerperienee feelings ofinlmehe~lpssn~~s,/eo~,orhorrofl YES NO
e. How much has this affected your life in the pas1 yea? (1) (2) 0) (4) (3
not st dl some extremely
11. Have you ever been emotionally abused or neglected (for example, being frequently shamed,
embarrassed, ignored, or repeatedly told ii~atyou were 'ko good")? YE3 NO
a. How old were you when thishappened? b. When it ended?
c. At the lime afthe event did you believe thatyou orsomeone elrecouldbe Mlled or seriauslyhnnnafl YES NO
d. At he time afhe evmt did youexperience feelings of inlmre he~lermes. fear, orhorrofl YES NO
e. How muchhas thin affected yaur life in the put year? (1) (2) (3) (4) (9
not at dl some ernemely
12. Have you ever been physically neglected (for example, not fed, not properly clothed, or left to take
care of yourself when you were too young or ill)? YES NO
a Haw oldwere you when thirhappned?
b. When itended7
c. At the time aftheevent did youbelieve thatyo~o~~omeone&e~~uldbeKdr reriourlyhnrmefl YES NO
d. At he time of Ule event did youexperience feelings of Irrlmsche~le3~nePs~fe~1,or horrofl
YES NO
c. How much has this affected your life in the past year? (1) (2) (3) (4) (3
not at dl some extremely
13. WOMENONLY:Have you ever had an abortion or miscarriage Oost your baby)? YES NO
a. How old were you when thishappened?
c. At hc the of theevent did youbelieve thatyou orrorneone&eeouldbeMIIedor seriousiylznnnefl YES NO
d At Ule time of the event did youexperience feelings ofinl~ehe@lessners,feo~, or ilorrofl
YES NO
e. How much has this affeeled your life in the past ye& (1) (z) (3) (4) (9
not st dl some erhemely
14. Have you ever been separated from you child against your will
(for example, the loss oCcustody or visitation or kidnapping)? YES NO
a How oldwere you when this happened?
b. When it ended?
e. How muchhas thL affected your life inthe past year? (1) (2) (3) (4) (9
not at PIU some ermmely
15. Has a baby or child of yours ever had a severe physical or mental handicap
(for example, mentally retarded, birth defects, can't hear, see, walk)?
YES NO
a How old were you whenthishappened?
b. When it ended?
e. How muchhas this affected your life inlhe put year? 0) 12) (3) (4) (3
not at dl some extremely
16. Have you ever been responsible for taking care of someone close to you (not your child)
who had a severe physical or n~ental handicap (for example,
cancer, stroke, AIDS, nerve problems, can't hear, see, walk)? YES NO
a How oldwere you when this happened?
b. When it ended?---
e. Howmchhasthisaffected your life in the past year? (1) (2) (3) (4) (3
not ot dl some extremely
17. Has someone close to you died suddenly or unexpectedly
(for example, sudden heart attack, murder or suicide)? YES NO
a. How old were you when thishappened? --
e. At thetime oftheevent did youbclicve thatyor orsorneone elsecouldbe killcdor seriouslylznnnadl YES NO
d. At metime oftheevent did you experience feelings ofinle,rr.i~c$lesmers. feoq orhorro* YES NO
e. How much has this affected your life in the part year? (1) (2) (3) (4) (5)
001 at dl some extremely
P P
DEPARTMENT OF VETERANS AFFAIRS
Pp--P
NATIONAL CENTER FOR PTSD