How often do you experience the following:
1) Repeated, disturbing memories, thoughts, images or dreams of a
stressful military experience from the past?
stressful military experience from the past?
2) Suddenly acting or feeling as if a stressful military experience were
happening again (as if you were re-living it)?
happening again (as if you were re-living it)?
3) Feeling very upset when something reminded you of a stressful
military experience from the past?
military experience from the past?
4) Having physical reactions (e.g. heart pounding, trouble breathing, or
sweating) when something reminded you of a stressful military
experience from the past?
sweating) when something reminded you of a stressful military
experience from the past?
5) Avoided thinking about or talking about a stressful military
experience from the past or avoided having feelings related to it?
experience from the past or avoided having feelings related to it?
6) Loss of interest in things that you used to enjoy?
7) Feeling emotionally numb, distant, cut-off, or being unable to have
loving feelings for those close to you?
loving feelings for those close to you?
12) Feeling as if your future will somehow be cut short?
9) Trouble falling or staying asleep?
10) Often feeling irritable or having angry outbursts?
11) Avoid activities or situations because they remind you of a
stressful military experience from the past?
stressful military experience from the past?
8) Trouble remembering important parts of a stressful military
experience from the past?
experience from the past?
13) Having difficulty concentrating?
14) Being "super alert" or "watchful", on guard?
15) Feeling jumpy or easily startled?
Veterans: Before taking the Warrior Breath Workshop we request that you fill out this survey. We are a private nonprofit organization, not connected with the government, military or VA. All information is strictly confidential. If you prefer, you do not have to supply your last name or phone number, just give us some way to contact you. |
Your Name:
Email Address:
Phone Number:
SURVEY
Please Press 'Submit' when finished.
| Please press the 'Submit' button at the bottom when you have completed the survey. |
Your City: