PSS Adult

PSS Adult

PTSD Symptom Scale
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Below is a list of traumatic events or situations. Please mark YES if you have experienced or witnessed the following events or mark NO if you have not had that experience.

Rows	Yes	No
1. Serious accident, fire or explosion
2. Natural disaster (tornado, flood, hurricane, major earthquake)
3. Non-sexual assault by someone you know (physically attacked/injured)
4. Non-sexual assault by a stranger
5. Sexual assault by a family member or someone you know
6. Sexual assault by a stranger
7. Military combat or a war zone
8. Sexual contact before you were age 18 with someone who was 5 or more years older than you
9. Imprisonment
10. Torture
11. Life-threatening illness
12. Other traumatic event

13. If "Other traumatic event" is checked YES above; please write what the event was.
14. Of the question to which you answered YES, which was the worst?
Please list the question #
15. Which of the above incidences is the reason for which you are currently seeking treatment?
Please list the question #
IF you answered NO to all of the above questions, STOP
IF you answered YES to any of the above questions, please complete the rest of the form.

Please check YES or NO regarding the event listed in question 15.

Rows	YES	NO
Were you physically injured?
Was someone else physically injured
Did you think your life was in danger?
Did you think someone else's life was in danger?
Did you feel helpless?
Did you feel terrified?

Below is a list of problems that people sometimes have after experiencing a traumatic event. Please rate on a scale from 0-3 how much or how often these following things have occurred to you in the last two weeks:

0 - Not At All 1 - Once Per week or less/ a little bit/ one in a while 2 - 2 to 4 times per week/ somewhat/ half the time 3 - 3 to 5 or more times per week/ very much / almost always

Rows	0	1	2	3
1. Having upsetting thought or images about the traumatic event that come into your head when you did not want them to
2. Having bad dreams or nightmares about the traumatic event
3. Reliving the traumatic event (acting as if it were happening again)
4. Feeling emotionally upset when you are reminded of the traumatic event
5. Experiencing physical reactions when reminded of the traumatic event (sweating, increased heart rate)
6. Trying not to think or talk about the traumatic event
7. Trying to avoid activities or people that remind you of the traumatic event
8. Not being able to remember an important part of the traumatic event
9. Having much less interest or participating much less often in important activitie
10. Feeling distant or cut off from the people around you
11. Feeling emotionally numb (unable to cry or have loving feelings)
12. Feeling as if your future hopes or plans will not come true
13. Having trouble falling or staying asleep
14. Feeling irritable or having fits of anger
15. Having trouble concentrating
16. Being overly alert
17. Being jumpy or easily startled

Please mark YES or NO if the problems above interfered with the following:

Rows	Yes	No
1. Work
2. Household duties
3. Friendships
4. Fun/leisure activities
5. Schoolwoork
6. Family Relationships
7. Sex Life
8. General life satisfaction
9. Overall functioning

Should be Empty:

PSS Adult

IF you answered NO to all of the above questions, STOP

IF you answered YES to any of the above questions, please complete the rest of the form.

Below is a list of problems that people sometimes have after experiencing a traumatic event. Please rate on a scale from 0-3 how much or how often these following things have occurred to you in the last two weeks: