Checklist for DSM-5

PART 1

Instructions: Listed below are a number of difficult or stressful things that sometimes happen to people. For each
event check one or more of the boxes to the right to indicate that:

(a) it happened to you personally;
(b) you witness edit happen to someone else;
(c) you learned about it happening to a close family member or close friend;
(d) you were exposed to it as part of your job (for example, paramedic, police, military, or other first responder);
(e) you’re not sure if it fits; or
(f ) it doesn’t apply to you.

Rows	Happened to me	Witnessed it	Learned about it	Part of my job	Not sure	Doesn’t apply
1.Natural disaster (for example,flood,hurricane ,tornado,earthquake)
2.Fire or explosion
3.Transportation accident (for example, car accident, boat accident, boat accident, train wreck, plane crash)
4.Serious accident at work, home, or during recreational activity
5.Exposure to toxic substance (for example,dangerous chemicals, radiation)
6.Physical assault (for example, being attacked, hit,slapped, kicked, beaten up)
7.Assault with a weapon (for example, being shot, stabbed, threatened with a knife, gun,bomb)
8.Sexual assault (rape, attempted rape, made to perform any type of sexual act through force or threat of harm)
9.Other unwanted or uncomfortable sexual experience
10.Combat or exposure to a war-zone (in the military or as a civilian)
11.Captivity (for example, being kidnapped,abducted, held hostage, prisoner of war)
12.Life-threatening illness or injury
13.Severe human suffering
14.Sudden violent death (for example, homicide,suicide)
15.Sudden accidental death
16.Serious injury, harm, or death you caused to someone else
17.Any other very stressful event or experience

(for example, what happened, who was involved, etc.)

(please estimate if you are not sure)

It happened to me directlyI witnessed itI learned about it happening to a close family member or close friendOther

Yes, my lifeYes, someone else’s lifeNo

Yes, I was seriously injuredYes, someone else was seriously injured or killedNo

Accident or violenceNatural causesNot applicable (The event did not involve the death of a close family member or close friend)

Just onceMore than once (please specify or estimate the total number of times you have had this experience

Rows	Not at all	A little bit	Moderately	Quite a bit	Extremely
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 (as if you were actually back there reliving it)?
Feeling very upset when something reminded you of the stressful experience?
Having strong physical reactions when something you of the stressful experience (for example, heart reminded pounding, trouble breathing, sweating)?
Avoiding memories, thoughts, or feelings related to the stressful experience?
Avoiding external reminders of the stressful experience (for Trouble remembering important parts of the stressful experience?
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)?
Blaming yourself or someone else for the stressful experience or what happened after it?
Having strong negative feelings such as fear, horror, anger,guilt, or shame?
Loss of interest in activities that you used to enjoy?
Feeling distant or cut off from other people?
Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
Irritable behavior, angry outbursts, or acting aggressively?
Taking too many risks or doing things that could cause you harm?
Being “super alert” or watchful or on guard?
Feeling jumpy or easily startled?
Having difficulty concentrating?
Trouble falling or staying asleep?

:HourMinutesAM/PM Option

PCL Checklist for DSM-5