INTERVIEWER REFERENCE CARD SIDE ONE

SCREENING SECTION (*SC)

POST TRAUMATIC STRESS DISORDER (*PT)

SC1. *SC3. *SC3a.

Rs AGE: _________ EVENT MARRIED MARRIAGE LIKE *PT29. COMBAT EXPERIENCE *PT30. RELIEF WORKER IN A WAR ZONE *PT31. CIVILIAN IN A WAR ZONE *PT32. CIVILIAN IN REGION OF TERROR *PT33. REFUGEE *PT34. KIDNAPPED *PT35. TOXIC CHEMICAL EXPOSURE *PT36. AUTOMOBILE ACCIDENT *PT37. OTHER LIFE-THREATENING ACCIDENT *PT38. NATURAL DISASTER *PT39. MAN-MADE DISASTER *PT40. LIFE-THREATENING ILLNESS *PT41. BEATEN UP AS A CHILD BY CAREGIVER *PT42. BEATEN UP BY A SPOUSE OR ROMANTIC PARTNER *PT43. BEATEN UP BY SOMEONE ELSE *PT44. MUGGED OR THREATENED WITH WEAPON *PT45. RAPED *PT46. SEXUALLY ASSAULTED *PT47. STALKED *PT48. UNEXPECTED DEATH OF A LOVED ONE *PT49. CHILDS SERIOUS ILLNESS SPECIFIC PHOBIA *PT50. TRAUMATIC EVENT TO LOVED ONE *PT50.1 WITNESSED PHYSICAL FIGHTS AT HOME *PT51. WITNESSED DEATH/ DEAD BODY/ SOMEONE SERIOUSLY HURT *PT52. ACCIDENTALLY CAUSED SERIOUS INJURY OR DEATH DEPRESSION *PT53. PURPOSELY INURED, TORTURED, OR KILLED SOMEONE *PT54. SAW ATROCITIES *PT54.1 OPTIONAL EVENT 1 *PT54.2 OPTIONAL EVENT 2 *PT54.3 OPTIONAL EVENT 3 MANIA *PT54.4 OPTIONAL EVENT 4 *PT54.5 OPTIONAL EVENT 5 *PT55. OTHER EVENT *PT57. PRIVATE EVENT

# TIMES SEQUENTIAL NUMBER

*SC7 EQUALS 1 *SC7 EQUALS 2 *SC20. *SC20a. *SC20.1 *SC20.2 *SC20.3 *SC21 *SC22 *SC23 *SC24 *SC25a *SC26 *SC26a *SC26b *SC27a. Animals *SC27b. Still Water *SC27c. Blood, Injury *SC27d.
Closed Spaces

*SC27e. High Places *SC27f. Flying *SC29 *SC29a *SC30 *SC31 *SC32 *SC33 *SC33.1 *SC33.2 *SC33.3 *SC34 *SC35

GROUP 1 Animals GROUP 2 Storms or Still Water GROUP 3 Blood, Injury, or Medical Experiences GROUP 4 Closed Spaces GROUP 5 High Places GROUP 6 Flying

sad / discouraged / uninterested several days / two weeks D29 # of episodes ________

happy or excited irritable

INTERVIEWER REFERENCE CARD SIDE TWO SERVICES PAST 12 MONTHS *SR5a *SR8
*SR10b

EVER QUIT

12 MON (CC4)

Ever Hospitalized Self Help Group Profession SR17 1 Psychiatrist 2 or Family or other Med. Dr. 4 Psychologist 5 Social Worker 6 Counselor 7 Other Mental Health 8 Nurse/ other hlth prof 9 Religious or Spiritual 10 Any Other Healer LONG/SHORT GROUP A B C D E F G H I J K L M N O

*SR20 *SR28 *SR41 *SR49 *SR58 *SR67 *SR75 *SR88 *SR101

*SR25a *SR38a *SR46b *SR55a *SR64a *SR72a *SR85a *SR98a *SR108a

CHRONIC CONDITIONS (*CC) KEY PHRASES EVER (CC1) a. Arthritis or rheumatism b. Back or neck problems c. Frequent or severe headaches d. (any other) Chronic pain e. Seasonal allergies f. Stroke g. Heart attack h. Heart disease i. High blood pressure j. Asthma k. Tuberculosis l. Chronic lung disease m. Malaria or other parasitic disease n. Diabetes or high blood sugar o. Ulcer p. Thyroid disease q. Neurological problems r. HIV infection s. Epilepsy or seizures t. Cancer 6.1.Accident/injury/poisoning

IWER -- CIRCLE RAMDOM CONDITION. PHARMACOEPIDEMIOLOGY (*PH) SEQUENTIAL MEDICINE NUMBER RANDOM MED #1 NAME: *PH4a *PH4b RANDOM MED #2 NAME: *PH4c *PH4d RANDOM MED #3 NAME: *PH4e *PH4f *PH4g *PH4h *PH4i *PH4j