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Patient Health Questionnaire – (PCL-5 PTSD)
uhs@CFBH
2024-06-10T14:39:40+00:00
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Patient Health Questionnaire – (PCL-5 PTSD)
Patient Health Questionnaire – (PCL-5 PTSD)
PCL 5-PTSD Checklist
Patient Name
*
First
Last
Date Completed
*
MM slash DD slash YYYY
Repeated, disturbing, and unwanted memories of the stressful experience?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Repeated, disturbing dreams of the stressful experience?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
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
Feeling very upset when something reminded you of the stressful experience?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
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
Avoiding memories, thoughts, or feelings related to the stressful experience?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
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
Trouble remembering important parts of the stressful experience?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
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
Blaming yoursef or someone else for the stressful experience or what happened after it?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Having strong negative feelings such as fear, horror, anger, guilt, or shame?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Loss of interest in activities that you used to enjoy?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Feeling distant or cut off from other people?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
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
Irritable behavior, angry outbursts, or acting aggressively?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Taking too many risks or doing things that could cause you harm?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Being "super-alert" or watchful or on guard?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Feeling jumpy or easily startled?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Having difficulty concentrating?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Trouble falling or staying asleep?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Program Type
*
PHP-5 day
Day IOP-3 day
Evening IOP
Adolescent IOP
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