| RPT |
|Safety Behavior Assessment Form - PTSD (SBAF-PTSD)
| Gender: <.Patient_Gender.>
|
|<*Answer_7771*>
|
| Raw scores range from 0-30, with higher scores suggestive of more frequent
| safety behavior usage.
|
|
|Questions and Answers:
|
|
| 1. Scope places out before entering
| <*Answer_8905*>
| 2. Sit with back to wall
| <*Answer_8906*>
| 3. Check yard or the area around your home ("Perimeter Checks")
| <*Answer_8907*>
| 4. Make up contingency plans in case someone is physically aggressive or
| there is some kind of emergency
| <*Answer_8908*>
| 5. Walk slowly to let someone pass who is close behind
| Date Given: <.Date_Given.>
| <*Answer_8909*>
| 6. Watch others for signs of danger
| <*Answer_8910*>
| 7. Check locks on doors or windows
| <*Answer_8911*>
| 8. Pretend I do not see or recognize someone so that I do not have to
| speak with them
| <*Answer_8912*>
| 9. Cut conversations short
| <*Answer_8913*>
| Clinician: <.Staff_Ordered_By.>
| 10. Leave events or activities early
| <*Answer_8914*>
|
|Information contained in this note is based on a self-report assessment
|and is not sufficient to use alone for diagnostic purposes. Assessment
|results should be verified for accuracy and used in conjunction with
|other diagnostic activities.
| Location: <.Location.>
|
| Veteran: <.Patient_Name_Last_First.>
| SSN: <.Patient_SSN.>
| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
|
