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PTSD Evaluation
PTSD Evaluation
"
*
" indicates required fields
PTSD Checklist (PCL) - 5
Name
*
First
Last
Date
MM slash DD slash YYYY
Instructions:
Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem carefully and then circle one of the numbers to the right to indicate how much you have been bothered by that problem in the past month.
In the past month, how much were you bothered by:
1. Repeated, disturbing, and unwanted memories of the stressful experience?
*
0 - Not at all
1 - A little bit
2 - Moderately
3 - Quite a bit
4 - Extremely
2. Repeated, disturbing dreams of the stressful experience?
*
0 - Not at all
1 - A little bit
2 - Moderately
3 - Quite a bit
4 - Extremely
3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
*
0 - Not at all
1 - A little bit
2 - Moderately
3 - Quite a bit
4 - Extremely
4. Feeling very upset when something reminded you of the stressful experience?
*
0 - Not at all
1 - A little bit
2 - Moderately
3 - Quite a bit
4 - Extremely
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?
*
0 - Not at all
1 - A little bit
2 - Moderately
3 - Quite a bit
4 - Extremely
6. Avoiding memories, thoughts, or feelings related to the stressful experience?
*
0 - Not at all
1 - A little bit
2 - Moderately
3 - Quite a bit
4 - Extremely
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?
*
0 - Not at all
1 - A little bit
2 - Moderately
3 - Quite a bit
4 - Extremely
8. Trouble remembering important parts of the stressful experience?
*
0 - Not at all
1 - A little bit
2 - Moderately
3 - Quite a bit
4 - Extremely
9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?
*
0 - Not at all
1 - A little bit
2 - Moderately
3 - Quite a bit
4 - Extremely
10. Blaming yourself or someone else for the stressful experience or what happened after it?
*
0 - Not at all
1 - A little bit
2 - Moderately
3 - Quite a bit
4 - Extremely
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?
*
0 - Not at all
1 - A little bit
2 - Moderately
3 - Quite a bit
4 - Extremely
12. Loss of interest in activities that you used to enjoy?
*
0 - Not at all
1 - A little bit
2 - Moderately
3 - Quite a bit
4 - Extremely
13. Feeling distant or cut off from other people?
*
0 - Not at all
1 - A little bit
2 - Moderately
3 - Quite a bit
4 - Extremely
14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
*
0 - Not at all
1 - A little bit
2 - Moderately
3 - Quite a bit
4 - Extremely
15. Irritable behavior, angry outbursts, or acting aggressively?
*
0 - Not at all
1 - A little bit
2 - Moderately
3 - Quite a bit
4 - Extremely
16. Taking too many risks or doing things that could cause you harm?
*
0 - Not at all
1 - A little bit
2 - Moderately
3 - Quite a bit
4 - Extremely
17. Being "superalert" or watchful or on guard?
*
0 - Not at all
1 - A little bit
2 - Moderately
3 - Quite a bit
4 - Extremely
18. Feeling jumpy or easily startled?
*
0 - Not at all
1 - A little bit
2 - Moderately
3 - Quite a bit
4 - Extremely
19. Having difficulty concentrating?
*
0 - Not at all
1 - A little bit
2 - Moderately
3 - Quite a bit
4 - Extremely
20. Trouble falling or staying asleep?
*
0 - Not at all
1 - A little bit
2 - Moderately
3 - Quite a bit
4 - Extremely
Add Total of All Numbers
*
Are You Human? Answer This: 2+2=?
*
