Operation Courage Assessment Form*

The questions in this evaluation ask you about your feelings and thoughts during the last two weeks to one month. In each case, you will be asked to indicate by selecting how often you felt or thought a certain way. There are four parts. *You must complete the evaluation in full to receive your results. The answers to this form are confidential, and will not be shared with employers or insurance companies in any way.

Part I: Perceived Stress Scale

In the last month, how often have you been bothered by any of the following problems?

(Select only one for each question)

1. How often have you been upset because of something that happened yesterday?
2. How often have you felt that you were unable to control the important things in your life?
3. How often have you felt nervous and “stressed”?
4. How often have you felt confident about your ability to handle your personal problems?
5. How often have you felt that things were going your way?
6. How often have you found that you could not cope with all the things that you had to do?
7. How often have you been able to control irritations in your life?
8. How often have you felt that you were on top of things?
9. How often have you been angered because of things that were outside of your control?
10. How often have you felt difficulties were piling up so high that you could not overcome them?
Continue to Part II

Part II: Patient Health Questionnaire (PHQ-9)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

(Select only one for each question)

1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself

Additional Questions

(Select only one)

10. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Continue to Part III

Part III: Generalized Anxiety Disorder Screener (GAD-7)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

(Select only one for each question)

1. Feeling nervous, anxious or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble Relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritated
7. Feeling afraid as if something awful might happen
8. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Additional Questions

(Select only one)

Q: When did the symptoms begin?
Continue to Part IV

Part IV: Impact of Events Scale-Revised (IES-R)

INSTRUCTIONS: Below is a list of difficulties people sometimes have after stressful life events. Please read each item, and then indicate how distressing each difficulty has been for you DURING THE PAST SEVEN DAYS with respect to the event you list below.

(Select only one for each question)

Q: What Event took place that caused you distress?
Q: What date did this event occur on?
1. Any reminder brought back feelings about it
2. I had trouble staying asleep
3. Other things kept making me think about it
4. I felt irritable and angry
5. I avoided letting myself get upset when I thought about it or was reminded of it
6. I thought about it when I didn't mean to
7. I felt as if it hadn't happened or wasn't real
8. I stayed away from reminders of it
9. Pictures about it popped into my head
10. I was jumpy and easily startled
11. I tried not to think about it
12. I was aware that I still had a lot of feelings about it, but I didn't deal with them
13. My feelings about it were kind of numb
14. I found myself acting or feeling like I was back in time
15. I had trouble falling asleep
16. I had waves of strong feelings about it
17. I tried to remove it from my memory
18. I had trouble concentrating
19. Reminders of it caused me to have physical reactions, such as sweating, trouble breathing, nausea, or a pounding heart
20. I had dreams about it
21. I felt watchful and on-guard
22. I tried not to talk about it
Continue to Part V

Part V: Alcohol Use Disorders Identification Test-Concise (AUDIT-C)

The Alcohol Use Disorders Identification Test-Concise (AUDIT-C) is a brief alcohol screening instrument. Please give a response for each question.

(Select only one for each question)

1. How often do you have a drink containing alcohol?
2. How many standard drinks containing alcohol do you have on a typical day?
3. How often do you have six or more drinks on one occasion?
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Evaluation Results

Part I: Perceived Stress Scale Results

Score Legend

0-13 = Low Stress
14-26 = Moderate Stress
27-40 High Perceived Stress

Part II: Patient Health Questionnaire (PHQ-9)

Score Legend

1-4 = Minimal Depression
5-9 = Mild Depression
10-14 = Moderate Depression
15-19 Moderately Severe Depression
20-27 Severe Depression

Part III: Generalize Anxiety Disorder Screener (GAD-7)

Score Legend

GAD-7 Score = 0-7
No Diagnosis
GAD-7 Score = 8+
Probably Anxiety Disorder

Part IV: Impact of Events Scale-Revised (IES-R)

Score Legend

24 or more = PTSD is a clinical concern. Those with scores this high who do not have full PTSD will have partial PTSD or at least some of the symptoms.
33 and above = This represents the best cutoff for a probably diagnosis of PTSD.
37 or more = This is high enough to suppress your immune system's functioning (even 10 years after an impact event).

Part V: AUDIT-C

Score Legend

The AUDIT-C is scored on a scale of 0-12 (scores of 0 reflect no alcohol use). In men, a score of 4 or more is considered positive; in women, a score of 3 or more is considered positive. Generally, the higher the AUDIT-C score, the more likely it is that the patient's drinking is affecting his/her health and safety.
Source: U.S. Department of Veteran Affairs

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