[form] Your Name please: [text,r_name,30] Email: [text,r_email,30] IMPACT OF EVENT SCALE Present Impact Profile for the past [list,time period] [option,Day,Day] [option,Week,Week] [option,2 weeks,2 weeks] [option,3 weeks,3 weeks] [option,Month,Month] [/list] ========================================================= Awareness of the Setting The UPSETTING EVENT that impacts you at present [textarea,upsetting event,2,70] Where are you when it impacts you? (familiar place, type of place...) [text,where I was,80] Who you are with at the time? [text,who I was with,80] WHEN does it impact you in terms of HOUR, DAY of week, MONTH? HOUR [list,HOUR] [option,1,1] [option,2,2] [option,3,3] [option,4,4] [option,5,5] [option,6,6] [option,7,7] [option,8,8] [option,9,9] [option,10,10] [option,11,11] [option,12,12] [/list][list,ampm] [option,am,am] [option,pm,pm] [/list] DAY [list,Day] [option,Monday,Monday] [option,Tuesday,Tuesday] [option,Wednesday,Wednesday] [option,Thursday,Thursday] [option,Friday,Friday] [option,Saturday,Saturday] [option,Sunday,Sunday] [/list] Other than the time frame above? If so please type in here... [text,other time frame,80] External triggers (body sensations, sounds, key words/phrases, smells, movements, objects, colours...) [textarea,external triggers,2,70] Internal Triggers (images, thoughts, moods) [textarea,internal triggers,2,70] ======================================================== Personal Impact in relation to the upsetting event 1. I think about it when I do not mean to. [radio,ies1,0 Not At All] Not At All [radio,ies1,1 Rarely] Rarely [radio,ies1,3 Sometimes] Sometimes [radio,ies1,5 Often] Often 2. I avoid letting myself get upset when I think about it or am reminded about it. [radio,ies2,0 Not At All] Not At All [radio,ies2,1 Rarely] Rarely [radio,ies2,3 Sometimes] Sometimes [radio,ies2,5 Often] Often 3. I try to remove it from memory [radio,ies3,0 Not At All] Not At All [radio,ies3,1 Rarely] Rarely [radio,ies3,3 Sometimes] Sometimes [radio,ies3,5 Often] Often 4. I have trouble falling asleep or staying asleep because of pictures or thoughts about it that come to my mind. [radio,ies4,0 Not At All] Not At All [radio,ies4,1 Rarely] Rarely [radio,ies4,3 Sometimes] Sometimes [radio,ies4,5 Often] Often 5. I have waves of strong feelings about it. [radio,ies5,0 Not At All] Not At All [radio,ies5,1 Rarely] Rarely [radio,ies5,3 Sometimes] Sometimes [radio,ies5,5 Often] Often 6. I have dreams about it. [radio,ies6,0 Not At All] Not At All [radio,ies6,1 Rarely] Rarely [radio,ies6,3 Sometimes] Sometimes [radio,ies6,5 Often] Often 7. I stay away from reminders about it. [radio,ies7,0 Not At All] Not At All [radio,ies7,1 Rarely] Rarely [radio,ies7,3 Sometimes] Sometimes [radio,ies7,5 Often] Often 8. I feel as if it hasn’t happened or was unreal. [radio,ies8,0 Not At All] Not At All [radio,ies8,1 Rarely] Rarely [radio,ies8,3 Sometimes] Sometimes [radio,ies8,5 Often] Often 9. I try not to talk about it. [radio,ies9,0 Not At All] Not At All [radio,ies9,1 Rarely] Rarely [radio,ies9,3 Sometimes] Sometimes [radio,ies9,5 Often] Often 10. Pictures about it pop into my mind. [radio,ies10,0 Not At All] Not At All [radio,ies10,1 Rarely] Rarely [radio,ies10,3 Sometimes] Sometimes [radio,ies10,5 Often] Often 11. Other things keep making me think about it. [radio,ies11,0 Not At All] Not At All [radio,ies11,1 Rarely] Rarely [radio,ies11,3 Sometimes] Sometimes [radio,ies11,5 Often] Often 12. I am aware that I still have a lot of feelings about it, but I do not deal with them. [radio,ies12,0 Not At All] Not At All [radio,ies12,1 Rarely] Rarely [radio,ies12,3 Sometimes] Sometimes [radio,ies12,5 Often] Often 13. I am trying not to think about it. [radio,ies13,0 Not At All] Not At All [radio,ies13,1 Rarely] Rarely [radio,ies13,3 Sometimes] Sometimes [radio,ies13,5 Often] Often 14. Any reminder brings back feelings about it. [radio,ies14,0 Not At All] Not At All [radio,ies14,1 Rarely] Rarely [radio,ies14,3 Sometimes] Sometimes [radio,ies14,5 Often] Often 15. My feelings about it are kind of numb [radio,ies15,0 Not At All] Not At All [radio,ies15,1 Rarely] Rarely [radio,ies15,3 Sometimes] Sometimes [radio,ies15,5 Often] Often ANY questions or comments? [textarea,questions or comments,3,70] PRINT out a copy of this page for your OWN RECORD before you click on SEND [submit,SEND this Entry][reset,Start Over again] [/form]