Hawaii Ketamine - (PCL) Screening for Post-Traumatic Stress Disorder

(PCL) Screening for Post-Traumatic Stress Disorder

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 select the option that indicates how much you have been bothered by the problem in the past month.

Rows	NOT AT ALL	A LITTLE BIT	MODERATELY	QUITE A BIT	EXTREMELY
Repeated disturbing memories, thoughts or images of the stressful experience?
Repeated, disturbing dreams of the stressful experience?
Suddenly acting or feeling as if the stressful experience were happening again (as if you were reliving it)?
Feeling very upset when something reminded you of the stressful experience?
Having physical reactions (e.g. heart pounding, trouble breathing, or sweating) when something reminded you of the stressful experience?
Avoiding thinking about or talking about the stressful experience or avoiding having feelings related to it?
Avoiding activities or situations because they remind you of the stressful experience?
Trouble remembering important parts of the stressful experience?

Rows	NOT AT ALL	A LITTLE BIT	MODERATELY	QUITE A BIT	EXTREMELY
Loss of interest in activities that you used to enjoy?
Feeling distant or cut off from other people?
Feeling emotionally numb or being unable to have loving feelings to those close to you?
Feeling as if your future will somehow be cut short?
Trouble falling or staying asleep?
Feeling irritable or having angry outbursts?
Having difficulty concentrating?
Being “super alert” or watchful or on guard?
Feeling jumpy or easily startled?

¿What are your goals pertaining to your ketamine journey and your mental health?

¿Who is your mental healthcare provider? We strongly suggest patients seeking Ketamine Therapy to have a mental health care practitioner or begin the process of getting established with one.

I answered all questions to the best of my knowledge and belief:

Name

First NameLast Name

Email

example@example.com

Date