Diagnostic form

The information below will make it easier for your therapist to understand your unique personal situation

Name

 

Gender  M    F   Age                              

Please circle only one  

Single   Married  Separated   Divorced

 

Length of service         —–––––––––           

Service arm.    Army   Navy    R A F     other

 

Tick the appropriate boxes relevant to your feelings:

 Sleep problems including nightmares and waking early.

 Flashbacks and replays which you are unable to switch off.

 Impaired memory, forgetfulness, inability to recall names, facts and dates that are well known to you.

 Impaired concentration.

 Impaired learning ability (eg through poor memory and inability to concentrate).

 Hyper vigilance (feels like but is not paranoia).

 Exaggerated startle response.

 Irritability, sudden intense anger, occasional violent outbursts.

 Panic attacks.

 Hypersensitivity, whereby every remark is perceived as critical.

 Obsessiveness - the experience takes over your life, you can't get it out of your mind.

 Joint and muscle pains which have no obvious cause.

 Feelings of nervousness, anxiety.

 Reactive depression (not endogenous depression).

 Excessive levels of shame, embarrassment. 

 Survivor guilt for having survived when others perished or for not having done more to help or save others.

 A feeling of having been given a second chance at life.

 Undue fear.

 Low self-esteem and shattered self-confidence.

 Emotional numbness, anhedonia (inability to feel love or joy).

 Feelings of detachment.

 Avoidance of anything that reminds you of the experience.

 Physical and mental paralysis at any reminder of the experience.

 

Indicate your service period

Palestine    1945 – 1948       Malaya 1948 – 1960          Korea           1950 - 1953

Canal Zone 1951 - 1954        Kenya  1952 - 1960           Cyprus         1955 - 1959

Aden          1955 - 1967        Radfan 1955 - 1967           Suez            1956

Borneo       1992 - 1966        N I       1969 - 2005           Oman Dhofar 1969 - 1976

Falklands   1982                  Gulf  1  1991                     Bosnia          1992

Kosovo       1999                 Sierra Leone 200               Afghanistan    2001

Iraq 2003

Other:::—-