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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
Cautious
Awed
Surprised
Content
Intimate
Scared
Angry
Inspired
Frustrated
Guilty
Never Rarely Sometimes Often Always
Energetic
Upset
Interested
Judged
Loyal
Proud
Determined
Alert
Special
Active
Never Rarely Sometimes Often Always
Dependable
Honorable
Joyful
Deceitful
Courageous
Disrespected
Hostile
Strong
Impulsive
Justified
Peaceful
Forgotten
Ashamed
 
 
 
Please select the traits that you witness from the veteran/service member (Select all that apply):
 
Volatile
 
Impulsive
 
Trustworthy
 
Hot-tempered
 
Defiant
 
Respectful
 
Confident
 
Racist
 
Independent
 
Controlled
 
Controlling
 
Emotional
 
Peaceful
 
Manipulative
 
Dedicated
 
Proud
 
Risk-Taker
 
Dependable
 
Responsible
 
Superiority
 
Extreme Bias
 
Even-tempered
 
Honest
 
Honorable
 
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 know less than I do.
They don’t appreciate me.
They are respectful.
They don’t trust me.
They can be trusted.
They are generally good.
They will lie to me.
They try to avoid me.
They blame me.
They are different from me.
Not at all like them A little like them Somewhat like them Very much like them Exactly like them
They want to be like me.
They are too trusting.
They want to help me.
They understand me.
They only pretend to be nice.
They are better than me.
They are unpredictable.
They are afraid of me.
They are weak.
They don’t see the “big picture”.
Not at all like them A little like them Somewhat like them Very much like them Exactly like them
They want to control me.
They get offended too easily.
They are easy to manipulate.
They will try to harm me or my family.
They feel sorry for me.
They are out to get me.