PTSD Questionnaire Patient Name *Phone Number *Email Address *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?YesNoHow did you experience it?It happened to me directlyI witnessed itI learned about it happening to a close family member or close friendI was repeatedly exposed to details about it as part of my job (for example, paramedic, police, military, or other first responder)Other, please describeIf 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 violenceNatural causesNot applicable (the event did not involve the death of a close family member or close friend)1. Repeated, disturbing, and unwanted memories of the stressful experience?Not at allA little bitModeratelyQuite a bitExtremely2. Repeated, disturbing dreams of the stressful experience?Not at allA little bitModeratelyQuite a bitExtremely3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?Not at allA little bitModeratelyQuite a bitExtremely4. Feeling very upset when something reminded you of the stressful experience?Not at allA little bitModeratelyQuite a bitExtremely5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?Not at allA little bitModeratelyQuite a bitExtremely6. Avoiding memories, thoughts, or feelings related to the stressful experience?Not at allA little bitModeratelyQuite a bitExtremely7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?Not at allA little bitModeratelyQuite a bitExtremely8. Trouble remembering important parts of the stressful experience?Not at allA little bitModeratelyQuite a bitExtremely9. 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 allA little bitModeratelyQuite a bitExtremely10. Blaming yourself or someone else for the stressful experience or what happened after it?Not at allA little bitModeratelyQuite a bitExtremely11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?Not at allA little bitModeratelyQuite a bitExtremely12. Loss of interest in activities that you used to enjoy?Not at allA little bitModeratelyQuite a bitExtremely13. Feeling distant or cut off from other people?Not at allA little bitModeratelyQuite a bitExtremely14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?Not at allA little bitModeratelyQuite a bitExtremely15. Irritable behavior, angry outbursts, or acting aggressively?Not at allA little bitModeratelyQuite a bitExtremely16. Taking too many risks or doing things that could cause you harm?Not at allA little bitModeratelyQuite a bitExtremely17. Being “superalert” or watchful or on guard?Not at allA little bitModeratelyQuite a bitExtremely18. Feeling jumpy or easily startled?Not at allA little bitModeratelyQuite a bitExtremely19. Having difficulty concentrating?Not at allA little bitModeratelyQuite a bitExtremely20. Trouble falling or staying asleep?Not at allA little bitModeratelyQuite a bitExtremely Submit
