PTSD Checklist (PCL-5)
Name:
*
Date of Birth:
*
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Month
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Day
Year
Date
Today’s Date
*
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Month
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Day
Year
Date
Instructions: Below is a list of problems that people sometimes have in response to a very stressful experience. Keeping your worst event in mind, please read each problem carefully and then select one of the numbers to the right to indicate how much you have been bothered by that problem in the past month.
Your Worst Event:
*
or type NA if not applicable
Your worst event:
*
Rows
Not at all
A little bit
Moderately
Quite a bit
Extremely
1. Repeated, disturbing, and unwanted memories of the stressful experience?
2. Repeated, disturbing dreams of the stressful experience?
3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
4. Feeling very upset when something reminded you of the stressful experience?
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?
6. Avoiding memories, thoughts, or feelings related to the stressful experience?
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?
8. Trouble remembering important parts of the stressful experience?
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)?
10. Blaming yourself or someone else for the stressful experience or what happened after it?
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?
12. Loss of interest in activities that you used to enjoy?
13. Feeling distant or cut off from other people?
14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
15. Irritable behavior, angry outbursts, or acting aggressively?
16. Taking too many risks or doing things that could cause you harm?
17. Being "superalert" or watchful or on guard?
18. Feeling jumpy or easily startled?
19. Having difficulty concentrating?
20. Trouble falling or staying asleep?
Total Score:
Cluster B:Re-experiencing:
Cluster C: Avoidance:
Cluster D: Negative alterations in mood and cognition:
Cluster E: Hyperarousal:
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Patient Health Questionnaire (PHQ-9)
Patient Name:
*
DOB:
*
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Month
-
Day
Year
Date
Date:
*
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Month
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Day
Year
Date
Over the last 2 weeks, how often have you been bothered by any of the following problems? Please select the appropriate number: 0 = not at all, 1 = several days, 2 = over half the days, 3 = nearly every day *
Over the last 2 weeks, how often have you been bothered by any of the following problems? Please select the appropriate number: 0 = not at all, 1 = several days, 2 = over half the days, 3 = nearly every day
*
Rows
0
1
2
3
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself in some way
Total
10. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? *
*
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
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Generalized Anxiety Disorder Assessment (GAD-7)
Patient Name:
*
DOB:
*
-
Month
-
Day
Year
Date
Date:
*
-
Month
-
Day
Year
Date
Over the last 2 weeks, how often have you been bothered by the following problems? Please select the appropriate number: 0 = not at all, 1 = several days, 2 = over half the days, 3 = nearly every day
Rows
0
1
2
3
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it's hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen
Total Score
If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?
*
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Submit
Should be Empty: