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Headstrong – Data Tracking Form
Headstrong – Data Tracking Form
Therapist Name
Patient Initials
Today's Date
Date Format: MM slash DD slash YYYY
Session #
1
8
16
24
Last
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?
Yes
No
2. Re-experiencing
*
e.g. intrusion, flashbacks, nightmares
Absent
Occasionally present
Persistent
Overall improvement?
Yes
No
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?
Yes
No
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?
Yes
No
5. Avoidance of feelings and/or situations
*
Absent
Occasionally present
Persistent
Overall improvement?
Yes
No
6. Suicidal ideation
*
Absent
Rare thoughts
Present
Overall improvement?
Yes
No
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?
Yes
No
8. Employment or education
*
Excellent performance
Moderate performance
Struggling
Overall improvement?
Yes
No
9. Current alcohol use*
*
*Use DSM-5 criteria
No diagnosis
Mild
Moderate
Severe
Overall improvement?
Yes
No
10. Current drug use*
*
*Use DSM-5 criteria
No diagnosis
Mild
Moderate
Severe
Overall improvement?
Yes
No
11. Medication
*
None
Reduced in dose or number of medications since psych evaluation
No change since psych evaluation
Overall improvement?
Yes
No
List psychiatric medications:
12. Treatment modalities
*
e.g. supportive, EMDR, DBT, IFS, SE, hypnosis, neuro-feedback. (May be more than one.)