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PTSD Study Page

PTSD Study Page

  • 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.

  • Very goodFairly goodFairly badVery bad
  • Not during the past monthLess than once a weekOnce or twice a weekThree or more times a week
  • Not during the past monthLess than once a weekOnce or twice a weekThree or more times a week
  • No problem at allOnly a very slight problemSomewhat of a problemA very big problem
  • No bed partner or roomatePartner/roomate in other roomPartner in same room, but not same bedPartner in same bed
  • Not during the past monthLess than once a weekOnce or twice a weekThree or more times a week
    (a)... loud snoring
    (b)... long pauses between breaths while asleep
    (c)... legs twitching or jerking white you sleep
    (d)... episodes of disorientation or confusion during sleep


  • 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.
  • YESSometimesNO
    E1 Because of my headaches I feel handicapped.
    E2 Because of my headaches I feel restricted in perfon-ning my routine daily activities.
    E3 No one understands the effect my headaches have on my life.
    E4 I restrict my recreational activities (eg. Sports, Hobbies) because of my headaches.
    E5 My headaches make me angry.
    E6 Sometimes I feel that I am going to lose control because of my headaches.
    E7 Because of my headaches I am less likely to socialize. _
    E8 My Spouse (significant other), or family and friends have no idea what I am going through because of my headaches.
    E9 My headaches are so bad that I feel that feel that I am going to go insane.
    E10 My outlook on the world is affected by my headaches.
    E11 I am afraid to go outside when I feel that a headache is starting.
    E12 I feel desperate because of my headaches.
    E13 I am concerned that I am paying penalties at work or at home because of my headaches.
    E14 My headaches place stress on my relationships with family or friends.
    El5 I avoid being around people when I have a headache.
    E16 I believe my headaches are making it difficult for me to achieve my goals in life.
    E17 I am unable to think clearly because of my headaches.
    E18 I get tense (eg. Muscle tension) because of my headaches.
    E19 I do not enjoy social gatherings because of my headaches.
    E20 I feel irritable because of my headaches.
    E21 I avoid traveling because of my headaches.
    E22 My headaches make me feel confused.
    E23 My headaches make me feel frustrated.
    E24 I find it difficult to read because of my headaches.
    E25 I find it difficult to focus my attention away from my headaches and on other things.

  • 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
  • 0123
    1 I found myself getting upset by quite trivial things
    2 I was aware of dryness of my mouth
    3 I couldn't seem to experience any positive feeling at all
    4 I experienced breathing difficulty (eg, excessively rapid 4 breathing, breathlessness in the absence of physical exertion)
    5 I just couldn't seem to get going
    6 I tended to over-react to situations
    7 I had a feeling of shakiness (eg, legs going o give way)
    8 I found it difficult to relax
    9 I found myself in situations that made me so anxious I was most relieved when they ended
    10 I felt that I had nothing to look forward to
    11 I found myself getting upset rather easily
    12 1 felt that I was using a lot of nervous energy
    13 I felt sad and depressed
    14 I found myself getting impatient when I was delayed in any way(eg, lifts, traffic lights, being kept waiting)
    15 I had a feeling of faintness
    16 I felt that 1 had lost interest in just about everything
    17 I felt I wasn't worth much as a person
    18 I felt that I was rather touchy
    19 I perspired noticeably (eg, hands sweaty) in the absence of high temperatures or physical exercises
    20 I felt scared without any good reason
    21 I felt that life wasn't worthwile
    22 I found it hard to wind down
    23 I had difficulty in swallowing
    24 I couldn't seem to get any enjoyment out of the things I did
    25 I was aware of the action of my heart in the absence of physical❑exertion (eg, sense of heart rate increase, heart missing a beat)
    26 I felt down-hearted and blue
    27 I found that I was very irritable
    28 I felt I was close to panic
    29 I found it hard to calm down after something upset me
    30 I feared that 1 would be "thrown" by some trivial butli unfamiliar task
    31 I was unable to become enthusiastic about anything
    32 I found it difficult to tolerate interruptions to what 1 was doing I was in a state of nervous tension
    33 I felt I was pretty worthless
    34 I felt terrified
    35 I was intolerant of anything that kept me from getting on with what I was doing
    36 I felt terrified
    37 I could see nothing in the future to be hopeful about
    38 I felt that life was meaningless
    39 I found myself getting agitated
    40 I was worried about situations in which I might panic and make a fool of myself
    41 I experienced trembling (eg in hands)
    42 I found it difficult to work up the initiative to do things

  • 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...
  • Not during the past monthLess than once a weekOnce or twice a weekThree or more times a week
    (a) ...cannot get to sleep within 30 minutes
    (b) ...wake up in the middle of the night or early morning
    (c) ...have to get up to use the bathroom
    (d) ...cannot breathe comfortably
    (e) ...cough or snore loudly
    (f) ...feel too cold
    (g) ...feel too hot
    (h) ...had bad dreams
    (i) ...have pain