Post-Traumatic Stress Disorder Questionnaire

Zia Health & Wellness
Medical Cannabis Program
Corporation                                                      


This questionnaire is not intended to diagnose. Patients must be evaluated and diagnosed by a licensed practitioner to enroll in the Medical Cannabis Program.


A person hoping to enroll under a PTSD diagnosis must meet the requirements in the following criterion A.


A person was exposed to one or more event(s) that involved death or threatened death, actual or threatened serious injury, actual or threatened sexual violation. In addition, these events were experienced in one or more of the following ways:

1. The event was experienced by the person
2. The event was witnessed by the person as it occurred to some one else
3. The person learned about the event where a close relative or friend experienced an actual or threatened violent or accidental death
4. The person experienced repeated exposure to distressing details of an event
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Q: Did you experience or witness a serious injury or death, or suffer the threat of injury or death?
Do you wish to continue *
In which state do you live? *
First and Last Name *
E-Mail Address *
Q: Have you experienced or been exposed to a traumatic event?
Q: During the traumatic event did you feel intense fear, helplessness, and/or horror?
Q: Do you regularly experience intrusive thoughts or images about the traumatic event?
Q: Do you sometimes feel like you are re-living the event or that it is happening all over again?
Q: Do you sometimes find yourself feeling traumatized or very frightened about something and cannot associate any memories with the feeling?
Q: Are you making efforts to avoid thoughts, feelings, or talking about the trauma?
Q: Do you avoid certain places, people, events and/or situations because they trigger (or might trigger) thoughts of the trauma?
Q: Are you unable to recall important aspects of the trauma?
Q: Do you feel detached or estranged from yourself and/or others?
Q: Are you experiencing problems with falling or staying asleep?
Q: Are you having trouble concentrating or are you irritable or jumpy?
Q: When you think about the future, do you get a sense that it will be shortened for some unknown reason?
Q: Have you felt irritable or have you had outbursts of anger?
Q: Do you often feel hypervigilant (constantly feeling and acting ready for any kind of threat)?
Q: Since the trauma took place, do you have difficulty experiencing or showing emotions?
Q: Have you had difficulty concentrating since the trauma?
Q: Have you been experiencing symptoms for more than one month?
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