Veteran’s Mental Health Assessment Checklist
Personal Information
Full Name
Date of Birth
Branch of Service
Years of Service
Current Mental Health Status
Mood:
Sleeping Patterns
Eating Habits
Symptoms Checklist
Anxiety
Depression
Irritability
Flashbacks
Avoidance
Hypervigilance
Difficulty Concentrating
Emotional Numbness
Support Systems
Describe support systems
Substance Use
Substance use history
Suicidal or Self-Harm Thoughts
Have you experienced thoughts of suicide or self-harm?
Yes
No
If yes, please provide details
Additional Comments