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Participant Exit Well Being Assessment
Name
*
First
Last
Below is a list of problems and complaints that veterans sometimes have in response to stressful life experiences. Please read each one carefully, and select the statement that best represents how much you have been bothered by that problem
in the last month.
Repeated, disturbing memories, thoughts, or images of a stressful experience from the past?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Repeated, disturbing dreams of a stressful experience from the past?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Suddenly acting or feeling as if a stressful experience were happening again (as if you were reliving it)?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Feeling very upset when something reminded you of a stressful experience from the past?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Having physical reactions (e.g., heart pounding, trouble breathing, or sweating) when something reminded you of a stressful experience from the past?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Avoid thinking about or talking about a stressful experience from the past or avoid having feelings related to it?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Avoid activities or situations because they remind you of a stressful experience from the past?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Trouble remembering important parts of a stressful experience from the past?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Loss of interest in things that you used to enjoy?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Feeling distant or cut off from other people?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Feeling emotionally numb or being unable to have loving feelings for those close to you?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Feeling as if your future will somehow be cut short?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Trouble falling or staying asleep?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Feeling irritable or having angry outbursts?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Having difficulty concentrating?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Being “super alert” or watchful on guard?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Feeling jumpy or easily startled?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
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