Dd Form 2795 - Privacy Act Statement (Sample) - Pre-Deployment Health Assessment Page 3
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7This form must be completed electronically. Handwritten forms will not be accepted.
Deployer’s SSN (Last 4 digits): _______________________
Below is a list of problems and complaints that people sometimes have in response to stressful life experiences. Please read each question
carefully and check the box for how much you have been bothered by that problem in the PAST MONTH. Please answer all items.
Not at all
A little bit
Moderately
Quite a bit
Extremely
11e. Repeated, disturbing memories, thoughts, or images of a
stressful experience from the past?
11f. Repeated, disturbing dreams of a stressful experience from
the past?
11g. Suddenly acting or feeling as if a stressful experience were
happening again (as if you were reliving it)?
11h. Feeling very upset when something reminded you of a
stressful experience from the past?
11i.
Having physical reactions (e.g., heart pounding, trouble
breathing, or sweating) when something reminded you of a
stressful experience from the past?
11j.
Avoid thinking about or talking about a stressful experience
from the past or avoid having feelings related to it?
11k. Avoid activities or situations because they remind you of a
stressful experience from the past?
11l.
Trouble remembering important parts of a stressful
experience from the past?
11m. Loss of interest in things that you used to enjoy?
11n. Feeling distant or cut off from other people?
11o. Feeling emotionally numb or being unable to have loving
feelings for those close to you?
11p. Feeling as if your future will somehow be cut short?
11q. Trouble falling or staying asleep?
11r. Feeling irritable or having angry outbursts?
11s. Having difficulty concentrating?
11t. Being “super alert” or watchful, on guard?
11u. Feeling jumpy or easily startled?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
11v. How difficult have these problems (11e. through
11u) made it for you to do your work, take care of
things at home, or get along with other people?
12. Over the LAST 2 WEEKS, how often have you been bothered by the following problems?
Not at all
Few or several days
More than half the days
Nearly every day
a. Little interest or pleasure in doing things
b. Feeling down, depressed, or hopeless
NOTE: If 12a. or 12b. are marked “More than half the days” or “Nearly every day,” continue to answer items 12c. through 12i.
Over the LAST 2 WEEKS, how often have you been bothered by any
Few or several
More than half
Not at all
Nearly every day
of the following problems?
days
the days
12c. Trouble falling/staying asleep, sleep too much.
12d. Feeling tired or having little energy.
12e. Poor appetite or overeating.
12f. Feeling bad about yourself – or that you are a failure or have
let yourself or your family down.
12g. Trouble concentrating on things, such as reading the
newspaper or watching television.
12h. Moving or speaking so slowly that other people could have
noticed. Or the opposite – being so fidgety that you have
been moving around a lot more than usual.
Not difficult
Somewhat
Extremely
Very difficult
at all
difficult
difficult
12i.
How difficult have these problems (12a.through12h.) made it
for you to do your work, take care of things at home, or get
along with other people?
None or
13. a. Over the PAST MONTH, what major life stressors have
Please list and explain: ___________________________
you experienced that are a cause of significant concern
or make it difficult for you to do your work, take care of
things at home, or get along with other people (for example,
______________________________________________
serious conflicts with others, relationship problems, or a
legal, disciplinary or financial problem)?
______________________________________________
Yes
No
b. Are you currently in treatment or getting professional
help for this concern?
DD FORM 2795, SEP 2012
Page 3 of 7 Pages
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