Psychological Assessment

PSYCHOLOGICAL ASSESSMENT

Psychological Assessment

Step 1 of 7

14%

GENERAL DATA

Name(Required)

First Last

SS Number(Required)

Branch of Service

Birthdate(Required)

MM slash DD slash YYYY

Date of Entry

Age(Required)

Date of Exit

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Location during assessment

Timezone (GMT)(Required)

WhatsApp or Viber (for consult):(Required)

Viber

Contact Number:(Required)

RELATIONSHIP HISTORY

How many times married

How many times divorced

List down significant romantic relationships and dates for how long they lasted and reason of separation or end of relationship:

Relationship List(Required)

Significant Relationship

Length of relationship (specify dates)

Reason for separation or end of relationship

Number of Children(Required)

OCCUPATIONAL AND EDUCATIONAL HISTORY

Educational Attainment(Required)

Occupational History(Required)

Jobs after leaving the military

Length of stay (specify dates)

Reason for leaving

LEGAL AND BEHAVIORAL HISTORY

Have you ever been arrested?(Required)

Yes

Explanation(Required)

Has a case been filed against you?(Required)

Yes

Explanation(Required)

Has the police ever been called on you?(Required)

Yes

Explanation(Required)

Ever been involved in public fight?(Required)

Yes

Explanation(Required)

SUBSTANCE USE HISTORY

Do you have a history of using alcohol, cigarette smoking or illicit drug use?(Required)

Yes

Which one?(Required)

Do you have history of abusing prescribed drugs such as opiates?(Required)

Yes

Which one?(Required)

Do you have a history of rehabilitation?(Required)

Yes

Specify dates(Required)

PAST PSYCHIATRIC HISTORY

Consult with a mental health professional or physician regarding mental health (inclusive dates)

Previous psychiatric diagnosis

Previous psychiatric confinement or drug rehabilitation (specify dates)

List of Medications Taken. Click the Plus icon (+) to add more

Family History of Mental Health Problems

ZUNG ANXIETY SELF-ASSESSMENT SCALE

Please read each statement and decide how much of the time the statement describes how you have been feeling during the past several days.

1. I feel more nervous and anxious than usual(Required)

A little of the time

Some of the time

Good part of the time

Most of the time

2. I feel afraid for no reason at all(Required)

A little of the time

Some of the time

Good part of the time

Most of the time

3. I get upset easily or feel panicky(Required)

A little of the time

Some of the time

Good part of the time

Most of the time

4. I feel like I'm falling apart and going to pieces(Required)

A little of the time

Some of the time

Good part of the time

Most of the time

5. I feel that everything is all right and nothing bad will happen(Required)

A little of the time

Some of the time

Good part of the time

Most of the time

6. My arms and legs shake and tremble(Required)

A little of the time

Some of the time

Good part of the time

Most of the time

7. I am bothered by headaches, neck and back pains(Required)

A little of the time

Some of the time

Good part of the time

Most of the time

8. I feel weak and get tired easily(Required)

A little of the time

Some of the time

Good part of the time

Most of the time

9. I feel calm and can sit still easily(Required)

A little of the time

Some of the time

Good part of the time

Most of the time

10. I can feel my heart beating fast(Required)

A little of the time

Some of the time

Good part of the time

Most of the time

11. I am bothered by dizzy spells(Required)

A little of the time

Some of the time

Good part of the time

Most of the time

12. I have fainting spells or feel faint(Required)

A little of the time

Some of the time

Good part of the time

Most of the time

13. I can breathe in and out easily(Required)

A little of the time

Some of the time

Good part of the time

Most of the time

14. I get feelings of numbness and tingling in my fingers and toes(Required)

A little of the time

Some of the time

Good part of the time

Most of the time

15. I am bothered by stomach aches or indigestion(Required)

A little of the time

Some of the time

Good part of the time

Most of the time

16. I have to empty my bladder often(Required)

A little of the time

Some of the time

Good part of the time

Most of the time

17. My hands are usually dry and warm(Required)

A little of the time

Some of the time

Good part of the time

Most of the time

18. My face gets hot and blushes(Required)

A little of the time

Some of the time

Good part of the time

Most of the time

19. I fall asleep easily and get a good night's rest(Required)

A little of the time

Some of the time

Good part of the time

Most of the time

20. I have nightmares(Required)

A little of the time

Some of the time

Good part of the time

Most of the time

ZUNG ANXIETY SELF-ASSESSMENT SCALE

Please read each statement and decide how much of the time the statement describes how you have been in the last few days.
Pakibasa ang mga pangungusap at pag-isipan kung gaano ninyo nararamdaman ang mga ito sa mga nakaraang araw

1. I feel down-hearted and blue.(Required)

(Pakiramdam ko ay malungkot at matamlay)

A little of the time (Hindi o madalang lang)