Ptsd Assessment printable pdf download

Ptsd Assessment

PTSD Assessment

Name: __________________________________ Date: ____________________

Below are some statements regarding how you may have felt and acted during the

past week. Please circle the number for each statement to indicate how often that

feeling or behavior has occurred.

Use the following scale:

0 = Not at all

1 = Only once during the week

2 = 2 or 3 times in the week

3 = 4 or 5 times in the week

4 = About once a day

5 = More than once a day

0 1 2 3 4 5 Bad dreams or nightmares.

0 1 2 3 4 5 Being especially alert or watchful, when there was no real need to be on guard.

0 1 2 3 4 5 Feeling in a daze.

0 1 2 3 4 5 Flashbacks of past unpleasant events.

0 1 2 3 4 5 Unexpected disturbing memories.

0 1 2 3 4 5 Feeling as if my emotions were shut down or blunted.

0 1 2 3 4 5 Working hard to block out certain memories.

0 1 2 3 4 5 Violent dreams.

0 1 2 3 4 5 Trying to avoid reminders of painful past events.

0 1 2 3 4 5 Checking to see that I was safe.

0 1 2 3 4 5 Jumping or being very frightened by sudden loud noises.

0 1 2 3 4 5 Acting or feeling as if I were re-experiencing some painful past event.

0 1 2 3 4 5 Distress caused by reminders of a painful past event.

0 1 2 3 4 5 Efforts to avoid reminders of a painful past event.

0 1 2 3 4 5 Feeling in danger.

0 1 2 3 4 5 Feeling out of touch with my surroundings.

0 1 2 3 4 5 Feeling that things going on around me were strange, unfamiliar or not quite real.

0 1 2 3 4 5 Feeling as if I were watching myself from outside of my body.

Ptsd Assessment