| RPT |
.|.|VETERANS AFFAIRS MILITARY STRESS TREATMENT ASSESSMENT, FORM B|Follow-Up Questionnaire||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran:
<*Answer_4890*>|1n. Inpatient or residential admission at a VA Medical Center for an emotional problem other than PTSD, substance use or suicide attempt| <*Answer_4891*>|2. How satisfied
overall are you with the care you received from the specialized PTSD program?| <*Answer_5007*>|3. How satisfied specifically are you with the changes you've made as a result of participating in
treatment?| <*Answer_5008*>|4. How satisfied are you specifically with the interactions you had with program staff?| <*Answer_5009*>|5. How satisfied are you specifically with the waiting time
for treatment by this program?| <*Answer_5010*>|6. How satisfied are you specifically with the arrangements to make women comfortable in coming to this program for treatment?|
<*Answer_5011*>|7. I have nightmares of experiences in the military that really happened.| <*Answer_4892*>|8. Lately, I have felt like killing myself.| <*Answer_4893*>|9. I fall asleep, stay
asleep and only awaken when it's time to get up.| <*Answer_4894*>|10. My dreams at night are so real that I waken in a cold sweat and force myself to stay awake.| <*Answer_4895*>|11. I feel
like I cannot go on.| <*Answer_4896*>|12. I do not laugh or cry at the same things other people do.| <*Answer_4897*>|13. I enjoy the company of others.| <*Answer_4898*>|14. I wonder why I am
still alive when others died in the military.| <*Answer_4899*>|15. Unexpected noises make me jump.| <*Answer_4900*>|16. There are times when I used alcohol (or other drugs) to help me sleep or
make me forget about things that happened while I was in the service.| <*Answer_4901*>|17. I lose my cool and explode over minor everyday things.| <*Answer_4902*>|18. I have a hard time
expressing my feelings, even to the people I care about.| <*Answer_4903*>|19. When I think of some of the things that I did in the military, I wish I were dead.| <*Answer_4904*>|20a. Repeated,
<.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||Type of Specialized PTSD Program:| <*Answer_4861*>|Admission Date to
disturbing memories, thoughts, or images of a stressful military experience?| <*Answer_4905*>|20b. Repeated, disturbing dreams of a stressful military experience?| <*Answer_4906*>|20c. Suddenly
acting or feeling as if a stressful military experience were happening again (as if you were reliving it)?| <*Answer_4907*>|20d. Feeling very upset when something reminded you of a stressful
military experience?| <*Answer_4908*>|20e. Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of a stressful military experience?|
<*Answer_4909*>|20f. Avoiding thinking about or talking about a stressful military experience or avoiding having feelings related to it?| <*Answer_4910*>|20g. Avoiding activities or situations
because they reminded you of a stressful military experience?| <*Answer_4911*>|20h. Trouble remembering important parts of a stressful military experience?| <*Answer_4912*>|20i. Loss of
interest in activities that you used to enjoy?| <*Answer_4913*>|20j. Feeling distant or cut off from other people?| <*Answer_4914*>|20k. Feeling emotionally numb or being unable to have loving
feelings for those close to you?| <*Answer_4915*>|20l. Feeling as if your future somehow will be cut short?| <*Answer_4916*>|20m. Trouble falling or staying asleep?| <*Answer_4917*>|20n.
Feeling irritable or having angry outbursts?| <*Answer_4918*>|20o. Having difficulty concentrating?| <*Answer_4919*>|20p. Being "superalert" or watchful or on guard?| <*Answer_4920*>|20q.
Feeling jumpy or easily startled?| <*Answer_4921*>|21. How well are you able to cope with military stress reactions so that they don't interfere too greatly with your life?|
<*Answer_4922*>|22a. Little interest or pleasure in doing things| <*Answer_4923*>|22b. Feeling down, depressed, or hopeless.| <*Answer_4924*>|22c. Trouble falling or staying asleep, or sleeping
this Program (mm/dd/yyyy):| <*Answer_4862*>|Date of this Report (mm/dd/yyyy):| <*Answer_4863*>|1a. Outpatient PTSD treatment from any VA medical center| <*Answer_4878*>|1b. Outpatient PTSD
too much.| <*Answer_4925*>|22d. Feeling tired or having little energy.| <*Answer_4926*>|22e. Poor appetite or overeating.| <*Answer_4927*>|22f. Feeling bad about yourself-or that you are a
failure or have let yourself or your family down.| <*Answer_4928*>|22g. Trouble concentrating on things, such as reading the newspaper or watching television.| <*Answer_4929*>|22h. Moving or
speaking so slowly that other people could have noticed? Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual.| <*Answer_4930*>|22i. Thoughts that
you would be better off dead or hurting yourself in some way.| <*Answer_4931*>|23. During the past month, my desire to make an active suicide attempt.| <*Answer_4932*>|24. During the past
month, I thought of suicide.| <*Answer_4933*>|25. During the past month, when I thought of suicide.| <*Answer_4934*>|26. Have you attempted suicide at any time in the last 4 months?|
<*Answer_4935*>|27. Do you have immediate access to loaded firearms that don't have trigger locks or other safety features (for example, by the bed, in the car, in the home)?| <*Answer_4936*>|28.
During the past month on average, how many hours of actual sleep did you get per night? (This may be different than the number of hours you spent in bed.) Round to the nearest whole hour.|
<*Answer_4937*>|29. During the past month, how would you rate your sleep quality overall?| <*Answer_4938*>|30. Did your use of alcohol in the past 4 months lead to any problems in your life, such
as in meeting your responsibilities or in your relationships with other people?| <*Answer_4939*>|31. How many days in the 4 months prior to beginning this program did you drink alcohol at all?|
<*Answer_4941*>|31a. How many days in the 4 months prior to beginning this program did you drink alcohol to the point where you felt drunk or intoxicated or had 3 or more drinks in one sitting?|
treatment from a Vet Center| <*Answer_4879*>|1c. Outpatient PTSD treatment from any non-VA program| <*Answer_4880*>|1d. Outpatient treatment of substance use problems from a VA addictions
<*Answer_4942*>|32a. I have been unhappy because of my drinking.| <*Answer_4943*>|32b. I have taken foolish risks when I have been drinking.| <*Answer_4944*>|32c. My physical health has been
harmed by my drinking.| <*Answer_4945*>|32d. My drinking has gotten in the way of my growth as a person.| <*Answer_4946*>|32e. My drinking has damaged my social life, popularity, or
reputation.| <*Answer_4947*>|32f. I have spent too much or lost a lot of money because of my drinking.| <*Answer_4948*>|32g. I have had an automobile accident or injured myself while drinking
or while intoxicated.| <*Answer_4949*>|33. Did your use of drugs, such as marijuana, heroin or cocaine, in the past 4 months lead to any problems in your life, such as in meeting your
responsibilities or in your relationships with other people? | <*Answer_4950*>|34. How many days in the past 4 months prior to beginning this program did you use drugs at all?|
<*Answer_4952*>|35a. Because of my drug use, I have not eaten properly.| <*Answer_4953*>|35b. I have failed to do what is expected of me because of my drug use.| <*Answer_4954*>|35c. I have
felt guilty or ashamed because of my drug use.| <*Answer_4955*>|35d. When using drugs, I have done impulsive things that I regretted later.| <*Answer_4956*>|35e. I have had money problems
because of my drug use.| <*Answer_4957*>|35f. My family has been hurt by my drug use.| <*Answer_4958*>|35g. A friendship or close relationship has been damaged by my drug use.|
<*Answer_4959*>|36. Overall, how would you rate your health during the past 4 weeks?| <*Answer_4960*>|37. During the past 4 weeks, how much did physical health problems limit your usual physical
activities (such as walking or climbing stairs)?| <*Answer_4961*>|38. During the past 4 weeks, how much difficulty did you have doing your daily work, both at home and away from home, because of
program| <*Answer_4881*>|1e. Outpatient treatment of substance use problems from a non-VA addictions program| <*Answer_4882*>|1f. Self-help groups for substance use problems (such as AA or NA)|
your physical health?| <*Answer_4962*>|39. How much bodily pain have you had during the past 4 weeks?| <*Answer_4963*>|40. During the past 4 weeks, how much energy did you have?|
<*Answer_4964*>|41. During the past 4 weeks, how much did your physical health or emotional problems limit your usual social activities with family or friends?| <*Answer_4965*>|42. During the past
4 weeks, how much have you been bothered by emotional problems (such as feeling anxious, depressed, or irritable)?| <*Answer_4966*>|43. During the past 4 weeks, how much did personal or emotional
problems keep you from doing your usual work, school or other daily activities?| <*Answer_4967*>|44. How many days have you experienced medical problems in the past 30 days? (Include both major
and minor ailments except temporary alcohol or drug problems. If no problems, enter "0"| <*Answer_4968*>|45. How troubled or bothered have you been by these medical problems in the past 30 days?|
<*Answer_4969*>|46. How important to you now is additional treatment beyond what you have been receiving all along for these medical problems?| <*Answer_4970*>|47. On average, about how many
cigarettes a day do you smoke? (1 pack is 20 cigarettes.)| <*Answer_4971*>|48. Over the past month, how often have you engaged in regular activities (for example, brisk walking, jogging,
bicycling, etc.) long enough to work up a sweat?| <*Answer_4972*>|49. 5ave you used any health care services for your physical health within the last year?| <*Answer_4973*>|50. I find strength
and comfort in my religion.| <*Answer_4974*>|51. My religion provides me with satisfying answers to questions about the meaning or purpose of life.| <*Answer_4975*>|52. My whole approach to
life is based on my religion.| <*Answer_4976*>|53. What religion offers me most is comfort in times of trouble and sorrow.| <*Answer_4977*>|54. I go to church mainly because I enjoy seeing
<*Answer_4883*>|1g. Individual meetings with a chaplain in the VA while you were an outpatient| <*Answer_4884*>|1h. Individual meetings with a chaplain in the VA while you were an inpatient|
people I know there.| <*Answer_4978*>|55. I feel God's presence.| <*Answer_4979*>|56. I feel deep inner peace or harmony.| <*Answer_4980*>|57. I feel God's love for me, directly or through
others.| <*Answer_4981*>|58. I am spiritually touched by the beauty of creation.| <*Answer_4982*>|59. How often do you attend religious services?| <*Answer_4983*>|60. How often do you pray
or meditate privately in places other than at a house of worship?| <*Answer_4984*>|61. What is your employment status?| <*Answer_4985*>|62. How many days did you work for pay during the past 30
days?| <*Answer_4986*>|63. During the past 4 months, how often have you had friends or relatives over to your home?| <*Answer_4987*>|64. About how often have you visited with friends or
relatives at their homes during the past 4 months?| <*Answer_4988*>|65. During the past 4 months, about how often did you go out with friends or relatives (for example, meet for coffee, go to a
movie, bowl, go to church)?| <*Answer_4989*>|66. About how often did you have telephone, mail, or computer contact with friends or relatives during the past 4 months?| <*Answer_4990*>|67. Did
you do any of these during the last 4 months? (Check all that apply)| <*Answer_4991*>|68. Got out of the house...| <*Answer_4992*>|69. Did an activity for pleasure or fun (for example, going
to a movie, going fishing, playing chess)...| <*Answer_4993*>|70. Did chores out in the community (for example, shopping, going to bank)...| <*Answer_4994*>|71a. Your life as a whole; that is,
your health, your relationships with other people, and your recreational activities overall?| <*Answer_4995*>|71b. The living arrangements where you live?| <*Answer_4996*>|71c. The way you
spend your free time?| <*Answer_4997*>|71d. The amount of time you spend with other people?| <*Answer_4998*>|71e. The amount of fun you have?| <*Answer_4999*>|71f. The way things are in
<*Answer_4885*>|1i. Individual meetings with a member of the clergy outside of the VA| <*Answer_4886*>|1j. Emergency room visits at any VA or non-VA medical center for PTSD-related problems|
general between you and your family?| <*Answer_5000*>|71g. The amount of friendship in your life?| <*Answer_5001*>|71h. How comfortable and well-off you are financially?|
<*Answer_5002*>|71i. Your physical condition?| <*Answer_5003*>|71j. Your emotional well-being?| <*Answer_5004*>|72. How effective has the care you received from this specialized PTSD program
been in helping you achieve your goals for entering treatment?| <*Answer_5005*>|73. How easy or difficult has it been for you to open up about yourself in treatment?| <*Answer_5006*>|74. How
likeable have you found your therapist(s) to be personally?| <*Answer_5012*>|75. How much competence and expertise has your therapist(s) shown in treating you?| <*Answer_5013*>|76. How much
have you and your therapist(s) agreed on the methods and goals of your treatment?| <*Answer_5014*>|77. How friendly and caring has the staff been toward you?| <*Answer_5015*>|78. How much has
your emotional or psychological health improved or not improved since you began treatment in this program?| <*Answer_5016*>|79. What is your treatment status currently?| <*Answer_5017*>| $~
<*Answer_4887*>|1k. Inpatient or residential admission for PTSD at a VA Medical Center for any PTSD-related problem (NOT substance use problems)| <*Answer_4888*>|1l. Inpatient or residential
admission at a VA Medical Center for substance use problems| <*Answer_4889*>|1m. Inpatient or residential admission at a VA Medical Center for a suicide attempt or concern about a suicide attempt|
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