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PTSD Checklist (PCL-5) (NM800038)

PTSD Checklist (PCL-5) (NM800038) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires



Patient Name

DOB:

MR #


NM#800038 Worksheet Only – Not a Medical Record Document
UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
PTSD CHECKLIST (PCL-5)




Instructions: Below is a list of problems that people sometimes have in response to a very stressful experience. Please read
each problem carefully and then circle one of the numbers to the right to indicate how much you have bene bothered by that
problem in the past month.

In the past month, how much were you bothered by:
Not
at all
A little
bit Moderately
Quite
a bit Extremely
1. Repeated, disturbing, and unwanted memories of the stressful
experience?
0 1 2 3 4
2. Repeated, disturbing dreams of the stressful experience? 0 1 2 3 4
3. Suddenly feeling or acting as if the stressful experience were
actually happening again, (as if you were actually back there
reliving it)?
0 1 2 3 4
4. Feeling very upset when something reminded you of the
stressful experience?
0 1 2 3 4
5. Having strong physical reactions when something reminded you
of the stressful experience (for example, heart pounding, trouble
breathing, sweating)?
0 1 2 3 4
6. Avoiding memories, thoughts, or feelings related to the stressful
experience?
0 1 2 3 4
7. Avoid external reminders of the stressful experience (for
example, people, places, conversations, activities, objects, or
situations)?
0 1 2 3 4
8. Trouble remembering important parts of the stressful
experience?
0 1 2 3 4
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)?
0 1 2 3 4
10. Blaming yourself or someone else for the stressful experience or
what happened after it? 0 1 2 3 4
11. Having strong negative feelings such as fear, horror, anger, guilt,
or shame? 0 1 2 3 4
12. Loss of interest in activities that you used to enjoy? 0 1 2 3 4
13. Feeling distant or cut off from other people? 0 1 2 3 4
14. Trouble experiencing positive feelings (for example, being
unable to feel happiness or have loving feelings for people close
to you)?
0 1 2 3 4
15. Irritable behavior, angry outbursts, or acting aggressively? 0 1 2 3 4
16. Taking too many risks or doing things that could cause you
harm? 0 1 2 3 4
17. Being “superalert” or watchful or on guard? 0 1 2 3 4
18. Feeling jumpy or easily startled? 0 1 2 3 4
19. Having difficulty concentrating? 0 1 2 3 4
20. Trouble falling asleep or staying asleep? 0 1 2 3 4



PCL-5 (8/14/2013) Weathers, Litz, Keane, Palmieri, Marx, & Schnurr – National Center for PTSD