Trauma & Stress Symptoms Questionnaire (PCL-5)

Trauma & Stress Symptoms Questionnaire

PCL-5
Patient Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Today's Date*

MonthDayYear
Date
For each of the questions below, keep your worst experience or event in mind, and read each problem carefully, then select one response to indicate how much you've been bothered by that problem in the past month.
In a few words, what was your stressful/traumatic event/experience?
Example: assault, near death experience, etc
1. Repeated, disturbing, and unwanted memories of the stressful experience?*

Not at allA little bitModeratelyQuite a bitExtremely
2. Repeated, disturbing dreams of the stressful experience?*

Not at allA little bitModeratelyQuite a bitExtremely
3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?*

Not at allA little bitModeratelyQuite a bitExtremely
4. Feeling very upset when something reminded you of the stressful experience?*

Not at allA little bitModeratelyQuite a bitExtremely
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?*

Not at allA little bitModeratelyQuite a bitExtremely
6. Avoiding memories, thoughts, or feelings related to the stressful experience?*

Not at allA little bitModeratelyQuite a bitExtremely
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)*

Not at allA little bitModeratelyQuite a bitExtremely
8. Trouble remembering important facts of the stressful experience?*

Not at allA little bitModeratelyQuite a bitExtremely
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)?*

Not at allA little bitModeratelyQuite a bitExtremely
10. Blaming yourself or someone else for the stressful experience o what happened after it?*

Not at allA little bitModeratelyQuite a bitExtremely
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?*

Not at allA little bitModeratelyQuite a bitExtremely
12. Loss of interest in activities that you used to enjoy?*

Not at allA little bitModeratelyQuite a bitExtremely
13. Feeling distant or cut off from other people?*

Not at allA little bitModeratelyQuite a bitExtremely
14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?*

Not at allA little bitModeratelyQuite a bitExtremely
15. Irritable behavior, angry outbursts, or acting aggressively?*

Not at allA little bitModeratelyQuite a bitExtremely
16. Taking too many risks or doing things that could cause you harm?*

Not at allA little bitModeratelyQuite a bitExtremely
17. Being superalert" or watchful or on guard?*

Not at allA little bitModeratelyQuite a bitExtremely
18. Feeling jumpy, or easily startled?*

Not at allA little bitModeratelyQuite a bitExtremely
19. Having difficulty concentrating?*

Not at allA little bitModeratelyQuite a bitExtremely
20. Trouble falling or staying asleep?*

Not at allA little bitModeratelyQuite a bitExtremely
Total Score:*
Cluster B Score:*
Cluster C Score:*
Cluster D Score:*
Cluster E Score:*
Total Score: 31-33 probable PTSD

Score of 2 or more=endorsed symptom

Cluster B (items 1-5): min 1 endorsed item

Cluster C (item 6-7): min 1 endorsed item

Cluster D (items 8-14): min 2 endorsed items

Cluster E (items 15-20): min 2 endorsed items
Should be Empty: