Eclipse Mental Health Services

PTSD Form

Please correct the errors described below.

Patient Name:

Date:

Trauma

In a brief sentence what was your traumatic event?

Please select each symptom that you experience:

Recurrent distressing memories

Recurrent dreams/nightmares

Flashbacks

Triggers causing emotional distress

Triggers causing physical distress

Avoiding memories of event

Avoiding reminders of event

Avoiding places of event

Difficulty remembering details of event

Persistent negative thoughts

Persistent guilt related to event

No interest in activities

Feeling detached from others

Unable to experience positive emotions

Irritability

Reckless behavior

Jumpy

Difficulty concentration

Poor sleep

How long would you estimate these symptoms have persisted?

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