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Surveys
2016
March
R
Relational Survey
Relational Survey
0%
Exit Survey
What is your current age?
What is your gender?
Male
Female
Have you ever served in the U.S. Military?
No
Yes, I am currently serving
Yes, I am currently on reserve status
Yes, I am retired
Yes, I was discharged from service
Branch of service:
What is your relation to the veteran/service member (Select all that apply)?
Spouse
Parent
Child
Other Relative
Caregiver
Close Friend
Other
How long have you known the veteran/Service member?
Are you currently living with the veteran/service member?
Yes
No
Other
Have you ever been diagnosed with PTSD or another mental illness (select all that apply):
No
Yes, but I am not experiencing symptoms – your PTSD is considered “cured” or is completely controlled by medications or therapy
Yes, I experience few or very mild symptoms – your PTSD can still be triggered, but you are always able to control it
Yes, I experience moderate symptoms – Your PTSD can still be triggered and you cannot always control it
Yes, my symptoms are severe – Your PTSD affects many areas of your life and you feel that you cannot control it
Other (please specify)
9. Please rate how often the veteran/service member displays or reports the following feelings or emotions:
Never
Rarely
Sometimes
Often
Always
Honorable
Forgotten
Upset
Surprised
Cautious
Strong
Content
Interested
Determined
Justified
Never
Rarely
Sometimes
Often
Always
Inspired
Scared
Deceitful
Active
Alert
Guilty
Courageous
Peaceful
Angry
Intimate
Never
Rarely
Sometimes
Often
Always
Proud
Disrespected
Awed
Ashamed
Hostile
Impulsive
Judged
Energetic
Special
Frustrated
Joyful
Loyal
Dependable
Please select the traits that you witness from the veteran/service member (Select all that apply):
Volatile
Dependable
Proud
Confident
Independent
Defiant
Emotional
Dedicated
Impulsive
Peaceful
Controlled
Hot-tempered
Extreme Bias
Risk-Taker
Superiority
Racist
Even-tempered
Honorable
Controlling
Honest
Respectful
Trustworthy
Responsible
Manipulative
Other (Please Specify Below)
Please rate the following statements according to how you feel about other people:
Not at all like them
A little like them
Somewhat like them
Very much like them
Exactly like them
They blame me.
They want to be like me.
They are afraid of me.
They don’t see the “big picture”.
They understand me.
They can be trusted.
They feel sorry for me.
They will lie to me.
They want to control me.
They will try to harm me or my family.
Not at all like them
A little like them
Somewhat like them
Very much like them
Exactly like them
They are better than me.
They are unpredictable.
They are weak.
They don’t trust me.
They get offended too easily.
They try to avoid me.
They are generally good.
They are out to get me.
They are easy to manipulate.
They only pretend to be nice.
Not at all like them
A little like them
Somewhat like them
Very much like them
Exactly like them
They are respectful.
They are different from me.
They don’t appreciate me.
They know less than I do.
They are too trusting.
They want to help me.
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