PTSD Evaluations

What do I
need?

A NEW MEXICO DRIVER'S LICENSE
OR ID CARD


This proves New Mexico residency. No other form of identification will be accepted by the department of health.

COMPLETE THE SCREENING FORM BELOW


The form must be completed before your appointment to ensure you meet the screening requirements.

Which of the following best describes your trauma?
Witnessing death or injuryPhysical assault/abuseCombat/military experienceMilitary sexual traumaSexual assault/rapeNatural disaster/fireChildhood sexual abuse/molestationAccident: MVA/boating/motorcycleIncarcerationSudden/traumatic death of a family member/friendFirst ResponderChildhood Physical AbuseChildhood Emotional AbuseChildhood Abandonment/NeglectDysfunctional UpbringingLife Threatening Experience

Repeated, disturbing, and unwanted memories of the stressful experience?
Not at allA little bitModeratelyQuite a bitExtremely

Nightmares or disturbing dreams?
Not at allA little bitModeratelyQuite a bitExtremely

Flashbacks?
Not at allA little bitModeratelyQuite a bitExtremely

Feeling very upset when something reminded you of the trauma?
Not at allA little bitModeratelyQuite a bitExtremely

Anxiety?
Not at allA little bitModeratelyQuite a bitExtremely

Avoiding memories of the trauma?
Not at allA little bitModeratelyQuite a bitExtremely

Avoiding reminders of the trauma?
Not at allA little bitModeratelyQuite a bitExtremely

Trouble remembering parts of the trauma?
Not at allA little bitModeratelyQuite a bitExtremely

Negative beliefs about yourself, others, or the world?
Not at allA little bitModeratelyQuite a bitExtremely

Blaming yourself or someone else for the trauma?
Not at allA little bitModeratelyQuite a bitExtremely

Fear, horror, anger, guilt or shame?
Not at allA little bitModeratelyQuite a bitExtremely

Loss of interest in activities you used to enjoy?
Not at allA little bitModeratelyQuite a bitExtremely

Feeling detached from others?
Not at allA little bitModeratelyQuite a bitExtremely

Trouble experiencing positive emotions?
Not at allA little bitModeratelyQuite a bitExtremely

Irritable, angry outbursts, or acting aggressively?
Not at allA little bitModeratelyQuite a bitExtremely

Risk-taking?
Not at allA little bitModeratelyQuite a bitExtremely

Being super-alert, watchful, or on-guard?
Not at allA little bitModeratelyQuite a bitExtremely

Easily startled?
Not at allA little bitModeratelyQuite a bitExtremely

Difficulty concentrating?
Not at allA little bitModeratelyQuite a bitExtremely

Trouble falling or staying asleep?
Not at allA little bitModeratelyQuite a bitExtremely

 

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