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Pcl-5 Form

PCL-5 Questionnaire

Name Date
Email Phone
Your worst event:

Instructions: Below is a list of problems that people sometimes have in response to a very stressful experience. Keeping your worst event in mind, please read each problem carefully and then select one of the numbers to the right to indicate how much you have been bothered by that problem in the past month.

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