Mood Assessment 2 - ACES, DASS-21 & PCL-5

Name

Date of Birth

MonthDayYear

Email

example@example.com

Date of Submission

Date

Please read each item carefully and choose the answer that best describes how you have felt over the past month.

Repeated, disturbing, and unwanted memories of the stressful experience?

Repeated, disturbing dreams of the stressful experience?

Suddenly feeling or acting as if the stressful experience were actually happening again?

Feeling very upset when something reminded you of the stressful experience?

Having strong physical reactions when something reminded you of the stressful experience?

Trouble remembering important parts of the stressful experience?

Loss of interest in activities that you used to enjoy?

Feeling distant or cut off from other people?

Trouble experiencing positive feelings?

Irritable or angry outbursts?

Taking too many risks or doing things that could cause you harm?

Being 'superalert', watchful, or on guard?

Feeling jumpy or easily startled?

Difficulty concentrating?

Trouble falling or staying asleep?

PCL-5 Total Score

PCL-5 Summary for Clinicians

Please answer each question based on your experiences growing up. Select the option that best fits each item.

Did a parent or other adult in the household often or very often swear at you, insult you, put you down, or humiliate you?

Did a parent or other adult in the household often or very often push, grab, slap, or throw something at you?

Did an adult or person at least 5 years older ever touch or fondle you or have you touch their body in a sexual way?

Did you often feel that no one in your family loved you or thought you were important or special?

Did you often feel that your family didn’t look out for each other, feel close to each other, or support each other?

Did you often feel that you didn’t have enough to eat, had to wear dirty clothes, or had no one to protect you?

Were your parents ever separated or divorced?

Was your mother or stepmother often or very often pushed, grabbed, slapped, or had something thrown at her?

Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?

Was a household member depressed or mentally ill, or did a household member attempt suicide?

Did a household member go to prison?

ACES Total Score

ACES Summary for Clinicians

Please answer each statement based on how much it applied to you over the past week. Choose one response for each item.

I found it hard to wind down.

I was aware of dryness of my mouth.

I couldn't seem to experience any positive feeling at all.

I experienced breathing difficulty (e.g., excessively rapid breathing, breathlessness in the absence of physical exertion).

I found it difficult to work up the initiative to do things.

I tended to over-react to situations.

I experienced trembling (e.g., in the hands).

I felt that I was using a lot of nervous energy.

I was worried about situations in which I might panic and make a fool of myself.

I felt that I had nothing to look forward to.

I found myself getting agitated.

I found it difficult to relax.

I felt down-hearted and blue.

I was intolerant of anything that kept me from getting on with what I was doing.

I felt I was close to panic.

I was unable to become enthusiastic about anything.

I felt I wasn't worth much as a person.

I felt that I was rather touchy.

I was aware of the action of my heart in the absence of physical exertion (e.g., heart rate increase, heart missing a beat).

I felt scared without any good reason.

I felt that life was meaningless.

DASS-21 Depression Score

DASS-21 Anxiety Score

DASS-21 Stress Score

DASS-21 Summary for Clinicians

Mood Assessments 2 - PCL5, ACES, DASS-21

PCL-5 (PTSD Checklist for DSM-5)

ACES (Adverse Childhood Experiences Survey)

DASS-21 (Depression, Anxiety, and Stress Scale - 21 Items)