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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
Awed
Inspired
Joyful
Deceitful
Upset
Scared
Determined
Guilty
Honorable
Never Rarely Sometimes Often Always
Active
Energetic
Peaceful
Strong
Courageous
Loyal
Judged
Ashamed
Surprised
Forgotten
Never Rarely Sometimes Often Always
Special
Content
Hostile
Proud
Justified
Interested
Disrespected
Angry
Frustrated
Dependable
Intimate
Impulsive
Cautious
 
 
 
Please select the traits that you witness from the veteran/service member (Select all that apply):
 
Emotional
 
Hot-tempered
 
Manipulative
 
Volatile
 
Dedicated
 
Responsible
 
Extreme Bias
 
Independent
 
Impulsive
 
Proud
 
Peaceful
 
Racist
 
Superiority
 
Risk-Taker
 
Controlled
 
Honest
 
Dependable
 
Defiant
 
Trustworthy
 
Honorable
 
Confident
 
Controlling
 
Even-tempered
 
Respectful
 
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 want to control me.
They try to avoid me.
They are unpredictable.
They only pretend to be nice.
They don’t appreciate me.
They don’t trust me.
They feel sorry for me.
They are easy to manipulate.
They are respectful.
They want to be like me.
Not at all like them A little like them Somewhat like them Very much like them Exactly like them
They are different from me.
They don’t see the “big picture”.
They want to help me.
They are weak.
They can be trusted.
They are afraid of me.
They blame me.
They will lie to me.
They are better than me.
They understand me.
Not at all like them A little like them Somewhat like them Very much like them Exactly like them
They will try to harm me or my family.
They are too trusting.
They know less than I do.
They are generally good.
They are out to get me.
They get offended too easily.