Form UCLA PTSD UCLA PTSD UCLA PTSD

UCLA PTSD INDEX FOR DSM-IV ©

Form Approved
OMB NO. 0930-0276
Exp. Date: xx-xx-xxxx
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-0276. Public
reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044,
Rockville, Maryland, 20857.

UCLA-PTSD INDEX FOR DSM-IV
(UCLA-PTSD)

/

DATE (Today’s Date)
Month

CHILD ID Number :

Day

Year

    -  -    






1998 Robert Pynoos, M.D., Ned Rodriguez, Ph.D
Alan Steinberg, Ph.D., Margaret Stuber, M.D.,
Calvin Frederick, M.D.









Contact: UCLA Trauma Psychiatry Service/ 300
UCLA Medical Plaza, Ste 2232
Los Angeles, CA 90095 -6968
(310) 206-8973/ EMAIL: [email protected]

ALL RIGHTS RESERVED/DO NOT duplicate or distribute without permission

UCLA PTSD INDEX FOR DSM-IV ©

Name:_____________________________ Child: ________ Age: ______
Sex: _______ Today’s Date:_______________ Week of Treatment: __________
Here is a list of problems people sometimes have after very bad things happen. Please think about the bad
thing that happened to you. Then, read each problem on the list carefully. CIRCLE one of the numbers
(0, 1, 2, 3, or 4) that tells how often the problem has happened to you in the past month. Use the Rating
Sheet on page 4 to help you decide how often the problem has happened in the last month.
PLEASE BE SURE TO ANSWER ALL QUESTIONS
None

Little

Some

Much

Most

0

1

2

3

4

2B4 When something reminds me of what happened, I get
very upset, afraid or sad.

0

1

2

3

4

3B1 I have upsetting thoughts, pictures or sounds
of what happened come into my mind when I do not
want them to.

0

1

2

3

4

4D2 I feel grouchy, angry or mad.

0

1

2

3

4

5B2 I have dreams about what happened or other bad
dreams

0

1

2

3

4

6B3 I feel like I am back at the time when the bad thing
happened, living through it again.

0

1

2

3

4

7C4 I feel like staying by myself and not being with my
friends.

0

1

2

3

4

8C5 I feel alone inside and not close to other
people.

0

1

2

3

4

9C1 I try not to talk about, think about, or have feelings
about what happened.

0

1

2

3

4

10C6 I have trouble feeling happiness or love.

0

1

2

3

4

11 C6I have trouble feeling sadness or anger.

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

1D4 I watch out for danger or things that I am afraid of.

12D5 I feel jumpy or startle easily, like when I hear a loud
noise or when something surprises me.
13D1 I have trouble going to sleep or I wake up often
during the night.
1998 Robert Pynoos, M.D., Ned Rodriguez, Ph.D
Alan Steinberg, Ph.D., Margaret Stuber, M.D.,
Calvin Frederick, M.D.

Contact: UCLA Trauma Psychiatry Service/ 300
UCLA Medical Plaza, Ste 2232
Los Angeles, CA 90095 -6968
(310) 206-8973/ EMAIL: [email protected]

ALL RIGHTS RESERVED/DO NOT duplicate or distribute without permission

UCLA PTSD INDEX FOR DSM-IV ©

14AF I think that some part of what happened is my fault.

0

1

2

3

4

15C3 I have trouble remembering important parts of what
happened.

0

1

2

3

4

16D3 I have trouble concentrating or paying attention.

0

1

2

3

4

17C2 I try to stay away from people, places, or things that
make me remember what happened.

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

B5

18 When something reminds me of what happened, I
have strong feelings in my body, like my heart beats
fast, my head aches, or my stomach aches.
C7

19 I think that I will not live a long life.
D2

20 I have arguments or physical fights.
21c7 I feel pessimistic or negative about my future.
22AFI am afraid that the bad thing will happen again.

1998 Robert Pynoos, M.D., Ned Rodriguez, Ph.D
Alan Steinberg, Ph.D., Margaret Stuber, M.D.,
Calvin Frederick, M.D.

Contact: UCLA Trauma Psychiatry Service/ 300
UCLA Medical Plaza, Ste 2232
Los Angeles, CA 90095 -6968
(310) 206-8973/ EMAIL: [email protected]

ALL RIGHTS RESERVED/DO NOT duplicate or distribute without permission

UCLA PTSD INDEX FOR DSM-IV ©

FREQUENCY RATING
SHEET
HOW OFTEN OR HOW MUCH OF THE TIME
DURING THE PAST MONTH, THAT IS SINCE
____________________,
DOES THE PROBLEM HAPPEN?

0

1

2

3

4

NONE

LITTLE

SOME

MUCH

MOST

S M T WH F S

S M T WH F S
X

S M T WH F S
X
X
X
X
X
X

S M T WH F S
X
X
X
X
X
X
X
X
X
X X X

X

NEVER

S MT
X X X
X X
X X
X X X

WH
X X
X X
X
X X

TWO TIMES 1-2 TIMES 2-3 TIMES
ALMOST
A MONTH
A WEEK
EACH WEEK EVERY DAY

1998 Robert Pynoos, M.D., Ned Rodriguez, Ph.D
Alan Steinberg, Ph.D., Margaret Stuber, M.D.,
Calvin Frederick, M.D.

Contact: UCLA Trauma Psychiatry Service/ 300
UCLA Medical Plaza, Ste 2232
Los Angeles, CA 90095 -6968
(310) 206-8973/ EMAIL: [email protected]

ALL RIGHTS RESERVED/DO NOT duplicate or distribute without permission

F S
X X
X
X X