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