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Exit Survey
 
 
What is your current age?
   
 
 
 
What is your gender?
 
Male
 
Female
 
 
 
Have you ever served in the U.S. Military?
 
No
 
Yes, I am currently serving
 
Yes, I am currently on reserve status
 
Yes, I am retired
 
Yes, I was discharged from service
 
Branch of service:
 

 
 
 
What is your relation to the veteran/service member (Select all that apply)?
 
Spouse
 
Parent
 
Child
 
Other Relative
 
Caregiver
 
Close Friend
 
Other
 

 
 
 
How long have you known the veteran/Service member?
   
 
 
 
Are you currently living with the veteran/service member?
 
Yes
 
No
 
Other
 
 
 
 
Have you ever been diagnosed with PTSD or another mental illness (select all that apply):
 
No
 
Yes, but I am not experiencing symptoms – your PTSD is considered “cured” or is completely controlled by medications or therapy
 
Yes, I experience few or very mild symptoms – your PTSD can still be triggered, but you are always able to control it
 
Yes, I experience moderate symptoms – Your PTSD can still be triggered and you cannot always control it
 
Yes, my symptoms are severe – Your PTSD affects many areas of your life and you feel that you cannot control it
 
Other (please specify)
 

 
 
9. Please rate how often the veteran/service member displays or reports the following feelings or emotions:
Never Rarely Sometimes Often Always
Alert
Frustrated
Justified
Active
Determined
Courageous
Loyal
Honorable
Deceitful
Ashamed
Never Rarely Sometimes Often Always
Inspired
Scared
Forgotten
Cautious
Peaceful
Angry
Awed
Proud
Special
Joyful
Never Rarely Sometimes Often Always
Judged
Upset
Strong
Energetic
Impulsive
Disrespected
Dependable
Hostile
Content
Guilty
Surprised
Intimate
Interested
 
 
 
Please select the traits that you witness from the veteran/service member (Select all that apply):
 
Even-tempered
 
Manipulative
 
Impulsive
 
Proud
 
Extreme Bias
 
Independent
 
Trustworthy
 
Superiority
 
Dependable
 
Confident
 
Dedicated
 
Emotional
 
Controlling
 
Racist
 
Risk-Taker
 
Volatile
 
Honest
 
Controlled
 
Responsible
 
Honorable
 
Hot-tempered
 
Respectful
 
Defiant
 
Peaceful
 
Other (Please Specify Below)

 
 
Please rate the following statements according to how you feel about other people:
Not at all like them A little like them Somewhat like them Very much like them Exactly like them
They will lie to me.
They will try to harm me or my family.
They are unpredictable.
They can be trusted.
They are easy to manipulate.
They understand me.
They are too trusting.
They don’t see the “big picture”.
They want to control me.
They are generally good.
Not at all like them A little like them Somewhat like them Very much like them Exactly like them
They are afraid of me.
They are different from me.
They are respectful.
They don’t appreciate me.
They try to avoid me.
They are out to get me.
They only pretend to be nice.
They are weak.
They blame me.
They know less than I do.
Not at all like them A little like them Somewhat like them Very much like them Exactly like them
They are better than me.
They want to be like me.
They get offended too easily.
They don’t trust me.
They want to help me.
They feel sorry for me.