PTSD Checklist Civilian Version with reporting

INSTRUCTIONS: Below is a list of problems and complaints that people sometimes have in response to stressful experiences. Please read each one carefully, select the response that best describes how much you have been bothered by that problem in the past month. Also, depending on how you answer the questions, you may be asked to provide some additional details about what has been going on. ANSWERING THE QUESTIONS ASKING FOR DETAILS IS OPTIONAL. Some of these questions may not be relevant to your situation.

Name *This question is required.

Date *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

1.) Repeated, disturbing memories, thoughts, or images of a stressful experience? *This question is required.

Describe the disturbing memories, thoughts, or images of the stressful experience that you have had. How often have you had them. Has it varied over time since the event?

2.) Repeated, disturbing dreams of a stressful experience from the past? *This question is required.

Describe the disturbing dreams of the stressful experience that you have had. How often have you had them. Has it varied over time?

3.) Suddenly acting or feeling as if a stressful experience were happening again? * *This question is required.

Give an example of suddenly acting or feeling as if the event was happening again. How often have you had this experience. Has it varied over time since the event?

4.) Feeling very upset when something reminded you of a stressful experience? *This question is required.

5.) Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of a stressful experience? *This question is required.

What kind of physical reactions (e.g., heart pounding, trouble breathing, sweating) have you had when something reminded you of a stressful experience? How often has this happened? Has it changed over time?

6.) Avoiding thinking about or talking about a stressful experience or avoiding having feelings related to it? *This question is required.

7.) Avoiding activities or situations because they reminded you of a stressful experience? *This question is required.

In what ways have you avoided thinking about or talking about a stressful experience or avoiding having feelings related to it?

What kind of activities or situations have you avoided because they reminded you of a stressful experience

8.) Trouble remembering important parts of a stressful experience? *This question is required.

Describe the difficulties that you have had remembering important parts of the stressful experience

9.) Loss of interest in activities that you used to enjoy? *This question is required.

Compare yourself before and after the event (s), what activities did you no longer participate in? What things did you find you no longer enjoyed?

10.) Feeling distant or cut off from other people? *This question is required.

11.) Feeling emotionally numb or being unable to have loving feelings for those close to you? *This question is required.

Thinking about your close family and friends, in what way did those relationships change before and after the event (s)?

12.) Feeling as if your future will somehow be cut short? *This question is required.

What hopes or dreams for the future that you had before the event (s) did you no longer have afterwards?

Think back to the time before the event (s), if you could have imagined your future life then, how would it have been different from the life that you actually had, or the life that you imagined that you would have after the event (s)?

13.) Trouble falling or staying asleep? *This question is required.

14.) Feeling irritable or having angry outbursts? *This question is required.

Describe the change in irritability that occurred after the event (s)... what kind of problems did you have afterwards that you didn't have before?

15.) Having difficulty concentrating? *This question is required.

16.) Being "super-alert" or watchful or on guard? *This question is required.

17.) Feeling jumpy or easily startled? *This question is required.

Describe situations and experiences of being hyperalert or being easily startled (if any) that you had after the event (s). How often did or do they happen?

PTSD Checklist Civilian Version with reporting - v2

PTSD Checklist Civilian Version