PTSD Questionnaire PTSD Questionnaire * Input number based on your choices: Not at all; A little bit; Moderately; Quite a bit; Extremely First Name Last Name Phone (###) ### #### Email * Briefly identify the worst event (if you feel comfortable doing so): * How long ago did it happen? * Did it involve actual or threatened death, serious injury, or sexual violence? Yes No How did you experience it? It happened to me directly I witnessed it I learned about it happening to a close family member or close friend I was repeatedly exposed to details about it as part of my job (for example, paramedic, police, military, or other first responder) Other, please describe Give details. If the event involved the death of a close family member or close friend, was it due to some kind of accident or violence, or was it due to natural causes? Accident or violence Natural causes Not applicable (the event did not involve the death of a close family member or close friend) IN THE PAST MONTH, HOW MUCH WERE YOU BOTHERED BY: 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 “super alert” 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 Thank you!
