Form 0920 Posttraumatic Stress Disorder -5

Attachment D9

Posttraumatic Stress Disorder -5

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/20xx

PTSD Checklist for DSM-5

Public reporting burden of this collection of information is estimated to average 2 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. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (XXXX).

VII. Below is a list of problems and complaints that people sometimes have in response to stressful life experiences. Please read each one carefully, then check one of the boxes on 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:		Not at All (0)	A Little Bit (1)	Moderately (2)	Quite a Bit (3)	Extremely (4)
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 (as if you were actually back there reliving it)?	□	□	□	□	□
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 (for example, heart pounding, trouble breathing, sweating)?	□	□	□	□	□
6	Avoiding memories, thoughts, or feelings related to the stressful experience?	□	□	□	□	□
7	Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?	□	□	□	□	□
8	Trouble remembering important parts of the stressful experience?	□	□	□	□	□
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)?	□	□	□	□	□
10	Blaming yourself or someone else for the stressful experience or what happened after it?	□	□	□	□	□
11	Having 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 (for example, being unable to feel happiness or have loving feelings for people close to you)?	□	□	□	□	□
15	Irritable behavior, angry outbursts, or acting aggressively?	□	□	□	□	□
16	Taking too many risks or doing things that could cause you harm?	□	□	□	□	□
17	Being "super-alert" or watchful or on guard?	□	□	□	□	□
18	Feeling jumpy or easily startled?	□	□	□	□	□
19	Having difficulty concentrating?	□	□	□	□	□
20	Trouble falling or staying asleep?	□	□	□	□	□

Interviewer _______