PCL - 5

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.

Patient Name

Patient Date of Birth

Date of Injury

Your worst event:

In the past month, how much were you bothered by:

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

Not at all (0) A little bit (1) Moderately (2) Quite a bit (3) Extremely (4)

2. Repeated, disturbing dreams of the stressful experience?

Not at all (0) A little bit (1) Moderately (2) Quite a bit (3) Extremely (4)

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 (0) A little bit (1) Moderately (2) Quite a bit (3) Extremely (4)

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

Not at all (0) A little bit (1) Moderately (2) Quite a bit (3) Extremely (4)

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

Not at all (0) A little bit (1) Moderately (2) Quite a bit (3) Extremely (4)

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

Not at all (0) A little bit (1) Moderately (2) Quite a bit (3) Extremely (4)

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

Not at all (0) A little bit (1) Moderately (2) Quite a bit (3) Extremely (4)

8. Trouble remembering important parts of the stressful experience?

Not at all (0) A little bit (1) Moderately (2) Quite a bit (3) Extremely (4)

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 (0) A little bit (1) Moderately (2) Quite a bit (3) Extremely (4)

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

Not at all (0) A little bit (1) Moderately (2) Quite a bit (3) Extremely (4)

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

Not at all (0) A little bit (1) Moderately (2) Quite a bit (3) Extremely (4)

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

Not at all (0) A little bit (1) Moderately (2) Quite a bit (3) Extremely (4)

13. Feeling distant or cut off from other people?

Not at all (0) A little bit (1) Moderately (2) Quite a bit (3) Extremely (4)

14. 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?

Not at all (0) A little bit (1) Moderately (2) Quite a bit (3) Extremely (4)

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

Not at all (0) A little bit (1) Moderately (2) Quite a bit (3) Extremely (4)

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

Not at all (0) A little bit (1) Moderately (2) Quite a bit (3) Extremely (4)

17. Being "superalert" or watchful or on guard?

Not at all (0) A little bit (1) Moderately (2) Quite a bit (3) Extremely (4)

18. Feeling jumpy or easily startled?

Not at all (0) A little bit (1) Moderately (2) Quite a bit (3) Extremely (4)

19. Having difficulty concentrating?

Not at all (0) A little bit (1) Moderately (2) Quite a bit (3) Extremely (4)

20. Trouble falling or staying asleep?

Not at all (0) A little bit (1) Moderately (2) Quite a bit (3) Extremely (4)

GAD - 7 Anxiety

Over the last two weeks, how often have you been bothered by the following problems?

1. Feeling nervous, anxious, or on edge

Not at all (0) Several days (1) More than half the days (2) Nearly everyday (3)

2. Not being able to stop or control worrying

Not at all (0) Several days (1) More than half the days (2) Nearly everyday (3)

3. Worrying too much about different things

Not at all (0) Several days (1) More than half the days (2) Nearly everyday (3)

4. Trouble relaxing

Not at all (0) Several days (1) More than half the days (2) Nearly everyday (3)

5. Being so restless that it is hard to sit still

Not at all (0) Several days (1) More than half the days (2) Nearly everyday (3)

6. Becoming easily annoyed or irritable

Not at all (0) Several days (1) More than half the days (2) Nearly everyday (3)

7. Feeling afraid, as if something awful might happen

Not at all (0) Several days (1) More than half the days (2) Nearly everyday (3)

Add up all of your responses and write down total score

Total Score:

If you checked any problems, how difficult have they 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

Scoring GAD-7 Anxiety Severity

This is calculated by assigning scores of O, 1, 2, and 3 to the response categories, respectively, of "not at all," "several days," "more than half the days," and "nearly every day." GAD-7 total score for the seven items ranges from 0 to 21.

0—4: minimal anxiety

5—9: mild anxiety

10—14: moderate anxiety

15—21: severe anxiety

PATIENT HEALTH QUESTIONNAIRE

(PHQ - 09)

Over the last 2 weeks how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things

Not at all (0) Several days(1) More than half the days(2) Nearly everyday(3)

2. Feeling down, depressed, or hopeless

Not at all (0) Several days(1) More than half the days(2) Nearly everyday(3)

3. Trouble falling or staying asleep, or sleeping too much

Not at all (0) Several days(1) More than half the days(2) Nearly everyday(3)

4. Feeling tired or having little energy

Not at all (0) Several days(1) More than half the days(2) Nearly everyday(3)

5. Poor appetite or overeating

Not at all (0) Several days(1) More than half the days(2) Nearly everyday(3)

6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down

Not at all (0) Several days(1) More than half the days(2) Nearly everyday(3)

7. Trouble concentrating on things, such as reading the newspaper or watching television

Not at all (0) Several days(1) More than half the days(2) Nearly everyday(3)

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

Not at all (0) Several days(1) More than half the days(2) Nearly everyday(3)

9. Thoughts that you would be better off dead or of hurting yourself in some way

Not at all (0) Several days(1) More than half the days(2) Nearly everyday(3)

Add up all of your responses and write down total score

Total Score:

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

Hamilton Anxiety Rating Scale (HAM-A)

1. ANXIOUS MOOD

SYMPTOMS

Worries

Fearful anticipation

Anticipation of the worst

Irritability

SEVERITY

0 1 2 3 4

2. TENSIONS

SYMPTOMS

Feelings of tension

Fatigability

Startles response

Easily moved to tears

Trembling

Feelings of restlessness

Inability to relax

SEVERITY

0 1 2 3 4

2. FEARS

SYMPTOMS

Fear of dark

Fear of strangers

Fear of being left alone

Fear of animals

Fear of traffic

Fear of crowds

SEVERITY

0 1 2 3 4

4. INSOMNIA

SYMPTOMS

Difficulty in falling asleep or staying asleep

Broken sleep

Night-terrors

Unsatisfying sleep and fatigue on waking

Dreams

Nightmares

SEVERITY

0 1 2 3 4

5. INTELLECTUAL

SYMPTOMS

Difficulty in concentration

Poor memory

SEVERITY

0 1 2 3 4

6. DEPRESSED MOOD

SYMPTOMS

Loss of interest In activities

Lack of pleasure in hobbies

Depression

Early waking

Diurnal swing

SEVERITY

0 1 2 3 4

7. SOMATIC COMPLAINTS: MASCULAR

SYMPTOMS

Pains and aches

Twitching, stiffness

Myoclonic jerks

Grinding of teeth (Bruxism)

Unsteady voice

Increased muscular tone

SEVERITY

0 1 2 3 4

8. SOMATIC COMPLAINTS: SENSORY

SYMPTOMS

Tinnitus

Blurring of vision

Hot and cold flushes

Feelings of weakness

Pricking sensation

SEVERITY

0 1 2 3 4

9. CARDIOVASCULAR SYMPTOMS

SYMPTOMS

Tachycardia

Palpitations

Chest Pain

Throbbing of vessels

Fainting feelings

Missing beat

Sensation of feeling faint

SEVERITY

0 1 2 3 4

10. RESPIRATORY SYMPTOMS

SYMPTOMS

Chest pressure or constriction

Choking feelings

Sighing

Dyspnea

Shortness of Breath

SEVERITY

0 1 2 3 4

11. GASTROINTESTINAL SYMPTOMS

SEVERITY

0 1 2 3 4

12. GENITOURINARY SYMPTOMS

SYMPTOMS

Frequency of micturition

Urgency of micturition

Amenorrhea

Menorrhagia

Development of frigidity

Premature ejaculation

Loss of libido

Impotence

SEVERITY

0 1 2 3 4

13. AUTONOMIC SYMPTOMS

SYMPTOMS

Dry mouth

Flushing

Pallor

Tendency to sweat

Giddiness

Tension headache

Raising of hair

SEVERITY

0 1 2 3 4

14. BEHAVIOUR AT INTERVIEW

SEVERITY

0 1 2 3 4

Add up severity of each column and write down your total score

Total Score:

Evaluation results interpretation:

14-17: Mild Anxiety;
18-24: Mild to Moderate Anxiety:
25-30: Moderate to Severe Anxiety

Checkbox list

Option 1

Option 2

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