PTSD Checklist
Instruction to patient: Below is a list of problems and complaints that veterans sometimes have in response to stressful life experiences. Please read each one carefully and indicate how much you have been bothered by that
problem in the last month.
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Your First Name, Last Initial *
Patient First Name, Last Initial *
Clinician
1. Repeated, disturbing, and unwanted memories, of the stressful experience? *
None
Extremely
2. Repeated, disturbing dreams of the stressful experience? *
None
Extremely
3. Suddenly acting or feeling as if the stressful experience were happening again (as if you were reliving it)? *
None
Extremely
4.  Feeling very upset when something reminded you of the stressful experience? *
None
Extremely
5. Having physical reactions (e.g., heart pounding, trouble breathing, or sweating) when something reminded you of the stressful experience? *
None
Extremely
6. Avoiding memories, thoughts, or feelings related to the stressful experience. *
None
Extremely
7. Avoiding external reminders of the stressful experience (for example, people, places, activities, objects, conversations, etc)? *
None
Extremely
8. Trouble remembering important parts of the stressful experience? *
None
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")? *
None
Extremely
10. Blaming yourself or someone else for the stressful experience or what happened after it? *
None
Extremely
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame? *
None
Extremely
12. Loss of interest in activities that you used to enjoy? *
None
Extremely
13. Feeling distant or cut off from other people? *
None
Extremely
14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)? *
None
Extremely
15. Irritable behavior, angry outbursts, or acting aggressively? *
None
Extremely
16. Taking too many risks or doing things that could cause you harm? *
None
Extremely
17. Being “superalert” or watchful or on guard? *
None
Extremely
18. Feeling jumpy or easily startled? *
None
Extremely
19. Having difficulty concentrating? *
None
Extremely
20. Trouble falling or staying asleep? *
None
Extremely
Reference
National Center for PTSD (29, April 2020). PTSD Checklist-5 (PCL-5).
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