DVMH

Da Vinci Mental Health

PTSD Intake & Assessment Module (Self-Report)

Progress

Please complete all sections below as thoroughly as possible. Fields marked * are required.

Patient Information

Patient First Name*

Patient Last Name*

Date of Birth*

Date of Birth is used to file this form with the correct patient record. (Not part of the original paper form.)

Date*

Section 1 - PTSD Screen (PCL-5 Style, Simplified)

Over the past 1 month, how much have you been bothered by the following problems related to a stressful or traumatic experience?*

(0 = Not at all | 1 = A little | 2 = Moderately | 3 = Quite a bit | 4 = Extremely)

Intrusion Symptoms

Question	0	1	2	3	4

Avoidance

Question	0	1	2	3	4

Negative Mood & Cognition

Question	0	1	2	3	4

Hyperarousal / Reactivity

Question	0	1	2	3	4

Total Score (out of 80)

Severity

Scoring: 0-20 Minimal | 21-30 Mild | 31-45 Moderate | 46+ Severe. Clinical threshold: a score of 33 or higher suggests probable PTSD.

Section 2 - Functional Impairment (Critical)

Daily Life Impact

Sleep & Nervous System

Cognitive & Emotional Impact

Section 3 - Trauma History (Brief, Optional)

Keep this minimal for intake safety. All items in this section are optional.

Type of trauma

Acute (single event) Chronic / repeated Developmental / childhood

Approximate timing

Recent Remote Ongoing

Section 4 - Clinical Red Flags

Please check if present

Suicidal thoughts Self-harm behaviors Dissociation episodes Panic attacks Substance use

Section 6 - Clinician Summary (MDM Ready)

For clinician completion.

PTSD Severity: - (from Section 1 total score)

Functional Impairment: - (from Daily Life Impact, worst of the three)

PTSD Severity

Functional Impairment

Risk Level

Automatically suggested based on the Clinical Red Flags and PTSD severity above. Please confirm or adjust as clinically appropriate -- this is a starting suggestion, not a determination.

Low Moderate High

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Thank you

Your assessment has been received. Our office will follow up if anything further is needed.