Author: Babu Dubey

PTSD Template designed by The Guiding Star, NLP Practitioner in Australia

General symptoms (choose at least three): *

• Negative Self-perception
• Nightmare/dreams
• Interpersonal Difficulties
• Lack of Expressing Feelings
• Mood Swings
• Avoiding Situations

Physical symptoms (choose at least two): *

• Insomnia
• Headache
• Gastrointestinal issues
• Skin disorder
• Rheumatic issues

Are You upset of being at the centre of the incident at least twice in last 7 days? (Choose)

• Yes
• No

Are you finding difficulty to concentrate at least twice in last 7 days? (Choose)

• Yes
• No

Unexpected thought comes to mind about that incident against your wish at least twice in last 7 days? (Choose)

• Yes
• No

Difficulty in falling asleep and staying asleep at least twice in last 7 days? (Choose)

• Yes
• No

Increased consciousness of potential dangers to You and Your Family at least twice in last 7 days? (Choose)

• Yes
• No

Are you getting any thought of self-harm at least twice in last 7 days? (Choose)

• Yes
• No

Personal Details *

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Last

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Email

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