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PTSD Study Page

PTSD Study Page

  • Date Format: MM slash DD slash YYYY

  • Authorization to Release Health Information for Research Purposes

  • What Infon-nation will be collected?

    Your doctor will be working with researchers at Life University in Marietta, Georgia to write a case report. This report will describe your experience under chiropractic care after it has already occurred. This is called a "retrospective" case study report.
    The Health Insurance Portability and Accountability Act (HIPAA) is a federal law passed to protect the privacy of your Protected Health Information (PHI). PHI is any information about you that could tell someone else who you are. We will not use or share you health information in any way other than what we explain in this form. We will keep yore health information private to the extent allowed by law. We will use a study nit nber or other code rather than your name on study records when we can. Your name of any other fact that might point to you will not appear if we publish the study results or make a presentation about the study,
    Signing this document means that you allow the researchers completing the case study to use your health information for this retrospective case study. Your doctor will make copies of your health records available to 'the researcher(s) so he/she can construct the report. All protected health, information in your records will be redacted or blacked out including:
    *Date of birth
    *Social security
    *Medical Record
    *Dates of admission, discharge, treatment or death
    *Health plan
    *Full face photogenic images or comparable images
    *Certificate / license
    *Diametric identifiers, including finger and voice prints
    *Vehicle identifiers, vehicle serial or license plate

    It is your choice to let the researcher(s) use your health information. You will receive a copy of this form.


  • INSTRUCTIONS: Please CIRCLE the correct response:
    1. I have headaches: (1) 1 Per month (2) More then I but less than 4 per month (3) More than one per week
    2. My headaches are: (1) Mild (2) Moderate (3) Severe

    Please Read Carefully: The purpose of the scale is to identify difficulties that you may be experiencing because of your headache. Please check off "YES", "SOMETIMES", or "NO" to each item. Answer each question as it pertains to your headache only.

  • DASS

  • Please read each statement and circle a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

    The rating scale is as follows:
    0 Did not apply to me at all
    1 Applied to me to some degree, or some of the time
    2 Applied to me to a considerable degree, or a good part of time
    3 Applied to me very much, or most of the time

  • Oxford Happiness Questionnaire

  • The Oxford Happiness Questionnaire was developed by psychologists Michael Argyle and Peter Hills at Oxford University.


    Below are a number of statements about happiness. Please indicate how much you agree or disagree with each by entering a number in the blank after each statement, according•to the following scale:
    1= strongly disagree
    2 = moderately disagree
    3 = slightly disagree
    4 = slightly agree
    5 = moderately agree
    6 = strongly agree
    Please read the statements carefully, some of the questions are phrased positively and others negatively. Don't take too long over individual questions; there are no "right" or "wrong" answers (and no trick questions). The first answer that comes into your head is probably the right one for you. If you find some of the questions difficult, please give the answer that is true for you in general or for most of the time.
    1. I don't feel particularly pleased with the way I am.
    2. I am intensely interested in other people.
    3. I feel that life is very rewarding.
    4. I have very warm feelings towards almost everyone.
    5. I rarely wake up feeling rested.
    6. I am not particularly optimistic about the future.
    7. I find most things amusing.
    8. I am always committed and involved.
    9. Life is good.
    10. I do not think that the world is a good place.
    11. I laugh a lot.
    12. I am well satisfied about everything in my life.
    13. I don't think I look attractive.
    14. There is a gap between what I would like to do and what I have done.
    15. l am very happy.
    16. I find beauty in some things.
    17. I always have a cheerful effect on others.
    18. I can fit in (find time for) everything I want to.
    19, I feel that I am not especially in control of my life.
    20, I feel able to take anything on.
    21. I feel fully mentally alert.
    22. I often experience joy and elation.
    23. I don't find it easy to make decisions.
    24. I don't have a particular sense of meaning and purpose in my life.
    25. I feel I have a great deal of energy.
    26. I usually have a good influence on events.
    27. I don't have fun with other people.
    28. I don't feel particularly healthy.
    29. I don't have particularly happy memories of the past.

    Calculate your score
    Step 1. Items marked (R) should be scored in reverse:
    For example, if you gave yourself a "1," cross it out and change it to a "6."
    Change "2" to a "5" Change "3" to a "4" Change "4" to a "3" Change "5" to a "2" Change "6" to a "1"
    Step 2. Add the numbers for all 29 questions. (Use the converted numbers for the 12 items that are reverse scored.)
    Step 3. Divide by 29. So your happiness score = the total (from step 2) divided by 29.


  • INSTRUCTIONS: The following questions relate to your usual sleep habits during the past month only. Your answers should indicate the most accurate reply for the majority of days and nights in the past month. Please answer all questions.
  • INSTRUCTIONS: For each of the remaining questions, check the one best response. Please answer all questions.

    5. During the past month, how often have you had trouble sleeping because you...