Severity of Posttraumatic Stress Symptoms

Severity of Posttraumatic Stress Symptoms - Adult*

*National Stressful Events Survey PTSD Short Scale (NSESSS)
Name*

First NameMiddle NameLast Name
Medical Record #*
Date

MonthDayYear
Date
Please list the traumatic event that you experienced:
Date of the traumatic event:

Instructions: People sometimes have problems after extremely stressful events or experiences. How much have you been bothered during the PAST SEVEN (7) DAYS by each of the following problems that occurred or became worse after an extremely stressful event/experience?

Rows	Not at all	A little bit	Moderately	Quite a bit	Extremely
Having “flashbacks,” that is, you suddenly acted or felt as if a stressful experience from the past was happening all over again (for example, you reexperienced parts of a stressful experience by seeing, hearing, smelling, or physically feeling parts of the experience)?
Feeling very emotionally upset when something reminded you of a stressful experience?
Trying to avoid thoughts, feelings, or physical sensations that reminded you of a stressful experience?
Thinking that a stressful event happened because you or someone else (who didn’t directly harm you) did something wrong or didn’t do everything possible to prevent it, or because of something about you?
Having a very negative emotional state (for example, you were experiencing lots of fear, anger, guilt, shame, or horror) after a stressful experience?
Losing interest in activities you used to enjoy before having a stressful experience?
Being “super alert,” on guard, or constantly on the lookout for danger?
Feeling jumpy or easily startled when you hear an unexpected noise?
Being extremely irritable or angry to the point where you yelled at other people, got into fights, or destroyed things?

Total / Partial Raw Score:
# of Questions Answered (9 total)*
Prorated Total Raw Score:
Average Total Score
Should be Empty:

Severity of Posttraumatic Stress Symptoms - Adult*