Acute Stress Symptoms Assessment -Adult Self Rated

Assessment 1 of 10

Form Instructions & Things to Know

How to fill this form:
  • Read each question carefully before selecting an answer.
  • Select the most accurate option based on your observations.
  • Do not skip questions; every response helps in the assessment.
Things to know:
10-15 Mins

Estimated completion time.

Secure

Your data is fully encrypted.

Note: This is a screening and assessment tool, not clinical (medical).

First, please provide your contact information.

Information about the individual being assessed.

1. Over the last 7 days, how often have you been bothered by having “flashbacks,” that is, you suddenly acted or felt as if a stressful experience from the past was happening all over again (for example, you reexperienced parts of a stressful experience by seeing, hearing, smelling, or physically feeling parts of the experience)?
2. Over the last 7 days, how often have you been bothered by feeling very emotionally upset when something reminded you of a stressful experience?
3. Over the last 7 days, how often have you been bothered by feeling detached or distant from yourself, your body, your physical surroundings, or your memories?
4. Over the last 7 days, how often have you been bothered by trying to avoid thoughts, feelings, or physical sensations that reminded you of a stressful experience?
5. Over the last 7 days, how often have you been bothered by being "super alert,” on guard, or constantly on the lookout for danger?
6. Over the last 7 days, how often have you been bothered by feeling jumpy or easily startled when you hear an unexpected noise?
7. Over the last 7 days, how often have you been bothered by being extremely irritable or angry to the point where you yelled at other people, got into fights, or destroyed things?