PCL-5 Below is a list of problems that people sometimes have in response to a very stressful experience. Answer these questions based on how you are feeling today. This field is hidden when viewing the formPatient NameName* First Last Today’s Date MM slash DD slash YYYY 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 Total Δ PCL-5 PTSD Checklist
