PCL

Name*

First NameLast Name

If an event listed on the Life Events Checklist happened to you or you witnessed it, please complete the items below. If more than one event happened, please choose the one that is most troublesome to you now.

The event you experienced was

on (date).

Date

Instructions: Below is a list of problems and complaints that people sometimes have in response to stressful life experiences. Please read each one carefully, then circle one of the numbers to the right to indicate how much you have been bothered by the problem in the past month. Section B (1 OVER 3)*

	Not at all (1)	A little bit (2)	Moderately (3)	Quite a bit (4)	Extremely (5)
1. Repeated disturbing memories, thoughts, or images of the stressful experience?
2. Repeated, disturbing dreams of the stressful experience?
3. Suddenly acting or feeling as if the stressful experience were happening again (as if you were reliving it)?
4. Feeling very upset when something reminded you of the stressful experience?
5. Having physical reactions (e.g., heart pounding, trouble breathing, or sweating) when something reminded you of the stressful experience?

Section C (3 OVER 3)*

	Not at all (1)	A little bit (2)	Moderately (3)	Quite a bit (4)	Extremely (5)
6. Avoiding thinking about or talking about the stressful experience or avoiding having feelings related to it?
7. Avoiding activities or situations because they remind you of the stressful experience?
8. Trouble remembering important parts of the stressful experience?
9. Loss of interest in activities that you used to enjoy?
10. Feeling distant or cut off from other people?
11. Feeling emotionally numb or being unable to have loving feelings for those close to you?
12. Feeling as if your future will somehow be cut short?

Section D (2 OVER 3)*

	Not at all (1)	A little bit (2)	Moderately (3)	Quite a bit (4)	Extremely (5)
13. Trouble falling or staying asleep?
14. Feeling irritable or having angry outbursts?
15. Having difficulty concentrating?
16. Being “super alert” or watchful or on guard?
17. Feeling jumpy or easily startled?

Office Use (PTSD if 44 or more; 50 if military)

CO-OCCURRING DISORDERS PROGRAM: SCREENING AND ASSESSMENT

Document is in the public domain. Duplicating this material for personal or group use is permissible.

Evergreen Youth & Family Services