PCL-5

Please answer the questions and submit the form

Client Information

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Last name

Instructions: Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem carefully and then select one of the options to indicate how much you have been bothered by that problem in the past month. The options include not at all, a little bit, moderately, quite a bit, and extremely.

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

Not at all A little bit Moderately Quite a bit Extremely

2. Repeated, disturbing dreams of the stressful experience?

Not at all A little bit Moderately Quite a bit Extremely

3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?

Not at all A little bit Moderately Quite a bit Extremely

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

Not at all A little bit Moderately Quite a bit Extremely

5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?

Not at all A little bit Moderately Quite a bit Extremely

6. Avoiding memories, thoughts, or feelings related to the stressful experience?

Not at all A little bit Moderately Quite a bit Extremely

7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?

Not at all A little bit Moderately Quite a bit Extremely

8. Trouble remembering important parts of the stressful experience?

Not at all A little bit Moderately Quite a bit Extremely

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)?

Not at all A little bit Moderately Quite a bit Extremely

10. Blaming yourself or someone else for the stressful experience or what happened after it?

Not at all A little bit Moderately Quite a bit Extremely

11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?

Not at all A little bit Moderately Quite a bit Extremely

12. Loss of interest in activities that you used to enjoy?

Not at all A little bit Moderately Quite a bit Extremely

13. Feeling distant or cut off from other people?

Not at all A little bit Moderately Quite a bit Extremely

14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?

Not at all A little bit Moderately Quite a bit Extremely

15. Irritable behavior, angry outbursts, or acting aggressively?

Not at all A little bit Moderately Quite a bit Extremely

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

Not at all A little bit Moderately Quite a bit Extremely

17. Being “superalert” or watchful or on guard?

Not at all A little bit Moderately Quite a bit Extremely

18. Feeling jumpy or easily startled?

Not at all A little bit Moderately Quite a bit Extremely

19. Having difficulty concentrating?

Not at all A little bit Moderately Quite a bit Extremely

20. Trouble falling or staying asleep?

Not at all A little bit Moderately Quite a bit Extremely

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