Brief Assessment - New Mexico 5-Actions Program™

"*" indicates required fields

I have someone who understands my problems.*

I have someone I trust to talk with about my feelings.*

I have someone to turn to for suggestions about how to deal with a problem.*

In the past month, have you had nightmares about a stressful experience or unwanted memories of it?*

Yes	No

Tried hard not to think about it or avoided reminders?*

Yes	No

Been constantly on guard, watchful, or easily startled?*

Yes	No

Felt numb or detached from people or activities?*

Yes	No

Felt guilty or unable to stop blaming yourself or others for what happened?*

Yes	No

Little interest or pleasure in doing things.*

Not at all	Several days	More than half	Nearly every day

Feeling down, depressed, or hopeless.*

Not at all	Several days	More than half	Nearly every day

Thoughts that you would be better off dead or of hurting yourself in some way.*

Not at all	Several days	More than half	Nearly every day

Feeling nervous, anxious, or on edge.*

Not at all	Several days	More than half	Nearly every day

Not being able to stop or control worrying.*

Not at all	Several days	More than half	Nearly every day

Have you tried to cut down or stop using a substance or behavior (gambling, sex, food) but couldn't?*

Yes	No

Has this caused problems with your health, work, finances, or relationships?*

Yes	No