PTSD Research Survey Form

Post Traumatic Stress Disorder Research Project

This survey form is designed to provide important information on the background, cause and triggers of Post Traumatic Stress Disorder (PTSD). We understand that it takes courage to take part in such work and we thank you from the bottom of our hearts.

The form should take about 30 minutes to complete, so please try to ensure you won't be disturbed while you are completing it. Answer the questions as best you can. There are no right or wrong answers but each answer is valuable to the research. At the end simply click on the Submit button to send the information.

We will make sure you receive a copy of the research report when it is issued. If you have any questions please email us at research@gmfint.com. Again, thank you very much for your help.

Please note: Some of these questions may bring unpleasant memories or emotional reactions. If so please ensure you have someone with you to support you in this endeavor. Whilst we appreciate and honor your willingness to help, we do not want to cause you unnecessary pain.

First, could you please give us some personal information for record only. This information will be kept ABSOLUTELY CONFIDENTIAL. No one will have access to it, ever. Your name and contact details will not appear anywhere in the research results. Please see our Confidentiality Declaration Please also read our disclaimer before you proceed
Your First name
Your Surname
Email Address
Country born in
Country living in now
How long have you lived there?
Religion you were raised in
Current religion if any
Year of birth
Current parental situation
Are you married?
How many children?
Do they still live with you?
Are you male or female?

The following questions relate to the appearance of PTSD in your life:

How old were you when the symptoms of PTSD first appeared?
How old are you now?
Do you know what event happened to trigger the first symptoms?	If "Other" please tell us what
How long after the event did you become aware that something was wrong?
Please tell us in your own words what happened. Take as much space as you need.
Were you alone or with a friend or family at the time of the event?
Did you feel alone or helpless at the time of the event?
Did time seem to slow down during the event?
The following questions relate to BEFORE the event that triggered the PTSD
Before the onset of PTSD symptoms were you aware of ongoing high anxiety levels?
If you answered YES above, how long were you aware of high anxiety levels?
Did you seek help or treatment or take any other action for that anxiety state prior to the event? If so please tell us what you did?	If more than one hold Ctrl key and select If Other selected please state what
Please describe your level of anxiety prior to the triggering event.	If more than one applies hold Ctrl key while selecting
The following questions relate to what happened AFTER the event that triggered the PTSD
After the triggering event, how long did it take for you to become aware that the symptoms were not normal?	Please select one
How long after becoming aware of the symptoms did you seek assistance?	Please select one
Did you discuss it with family or friends?
If you did discuss it, did they help, and if so, how?
If you sought the help of a professional counselor or other medical practitioner, who did you go to?	If more than one hold Ctrl key and select If Other selected please tell us who
Was the assistance they provided helpful in reducing the severity of the symptoms? How?
Were you placed on any medication?
If you were placed on medication, what was prescribed?
Did the medication help? What effect did it have?
These questions relate to how you feel about yourself and circumstances now
Do you feel loved?
Do you feel any guilt about anything related to the event?
If so what do you feel guilty about?
Do you feel rejected by family, friends or society?
Do you feel you are weak because you have not been able to beat this?
Do you feel someone should be able to help?

The following questions relate to HOW you perceive the symptoms that are often related to Post Traumatic Stress Disorder
Please select all the symptoms that you have or have had since their first onset.
	Severity on a scale of 1 - 10 where 10 is very severe	Add any comments you have on each symptom if you wish.
Anxiety
Panic attacks
Racing heart
Breathing shallow or difficult
Cold sweats
Anger
Depression and tears
Guilt
Difficulty sleeping
Muscle tension or spasms
Avoid people and places that remind me of the event
Flashbacks to the event
Nightmares of the event
Sometimes feel I am back in the event
Dizziness
I sometimes feel like the ground moves under me
Sometimes things seem to move in my peripheral vision that I know can't move
Colours seem different
I cannot think clearly
I sometimes have a metallic taste in my mouth
I lack energy most of the time
Other symptoms - please describe

This section is the last one. It provides us with information on HOW you process the symptoms that you have described. In the drop down boxes you may select more than one by holding down the Shift key and selecting the most applicable answers.
When you have memories or flashbacks, how do you become aware of them? Do you SEE them or do you FEEL them, or do you do both?
If you SEE them are you IN the picture or do you see it like on a movie screen in front of you?
If you SEE them are the colours bright, normal or subdued?
Please try to describe the images or movies in your own words
When you FEEL the symptoms where do you feel them in your body?
When you FEEL them, how do they feel?
Can you tell me more about the feelings? Please try to describe them in your own words


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That's all! At last! I know that was not easy for you and you have shown great patience. We have asked some very confronting questions, but your answers will help us formulate much better ways of treating and eliminating the symptoms you have been suffering from. Please now click on the Submit button