Council for Relationships - Helping people understand, respect, and improve the quality of their relationships - Headstrong

Therapist Name

Patient Initials

Today's Date

Session #

Please select and mark ONE relevant response to items 1-11 as they pertain to symptoms in the past 7- 30 days. Overall improvement refers only to symptom changes since the beginning of treatment. Please do not ask the veteran to score, but make your own assessment based on your clinical contact. If you wish, provide details.

1. Quality of sleep*

No disturbance
Occasional disturbance
Usually disturbed

Overall improvement?

2. Re-experiencing*

e.g. intrusion, flashbacks, nightmares

Absent
Occasionally present
Persistent

Overall improvement?

3. Arousal, reactivity, vigilance*

e.g. aggressive, reckless, outbursts of anger, irritable, self-destructive behavior, easily startled/distracted, jumpy, on edge, "on guard"

Absent
Occasionally present
Persistent

Overall improvement?

4. Quality of relationships*

e.g. detachment/engagement, distant or cut off from people, spouse, family, friends

Most relationships are very good
Intermittent tensions/arguments in relationships
Isolcated; few or poor relationships

Overall improvement?

5. Avoidance of feelings and/or situations*

Absent
Occasionally present
Persistent

Overall improvement?

6. Suicidal ideation*

Absent
Rare thoughts
Present

Overall improvement?

7. Mood*

e.g. difficulty enjoying things, hard to imagine having a long life span and fulfilling goals

Euthymic
Rarely depressed
Depressed 50% of the time
Rare good days
Consistently very depressed

Overall improvement?

8. Employment or education*

Excellent performance
Moderate performance
Struggling

Overall improvement?

9. Current alcohol use**

*Use DSM-5 criteria

No diagnosis
Mild
Moderate
Severe

Overall improvement?

10. Current drug use**

*Use DSM-5 criteria

No diagnosis
Mild
Moderate
Severe

Overall improvement?

11. Medication*

None
Reduced in dose or number of medications since psych evaluation
No change since psych evaluation

Overall improvement?

List psychiatric medications:

12. Treatment modalities*

e.g. supportive, EMDR, DBT, IFS, SE, hypnosis, neuro-feedback. (May be more than one.)

Headstrong – Data Tracking Form