Life Stressors Checklist

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Life Stressors Checklist - Revised

we are going to ask you some questions about events in your life that are frightening,
upsetting, or stressful to most people. Please think back over your whole life when you answer these questions.
Some of these questions may be about upsetting events you don’t usually talk about. Your answers are important, but you do not have to answer any questions that you do not want to. Thank you.

The LSC-R (1997) Is an open domain product of the National Center for PTSD.

Your First Name, Last initial *

Patient First Name, Last initial *

Clinician

1. Have you ever been in a serious disaster (for example, an earthquake, hurricane, large fire, explosion)? *

Yes

1a. If yes, how old were you?

1b. If yes, at the time of the event did you believe that you or someone else could be killed or seriously harmed?

Yes

Other:

Clear selection

1c. If yes, at the time of the event did you experience feelings of intense helplessness, fear, or horror?

Yes

Other:

Clear selection

1d. If yes, how much has this affected your life in the past year?

None

Extremely

Clear selection

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