PCL-5 Form





General Information




Today's Date

Invalid Input

Your Full Name(*)

The field above is a required field, please enter your information.

>


Date of Next Appointment (if scheduled)


Invalid Input


Date of Birth(*)
/ /

The field above is a required field, please enter your information.

>


Your Age

Invalid Input

Your Gender

Invalid Input

Home Phone

Invalid Input

Is it okay to leave a message at home?

Invalid Input

Work Phone

Invalid Input

Is it okay to leave a message at work?

Invalid Input

Cell Phone

Invalid Input

Other Phone

Invalid Input

Please let us know which phone number is your primary

Invalid Input

Your Address

Invalid Input

Email address if you would like us to provide reminders through email (versus phone)

Invalid Input


PCL-5

INSTRUCTIONS: Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each one carefully, 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:




1. Repeated, disturbing, and unwanted memories of the stressful experience?

Invalid Input

2. Repeated, disturbing dreams of the stressful experience?

Invalid Input

3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?

Invalid Input

4. Feeling very upset when something reminded you of the stressful experience?

Invalid Input

5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?

Invalid Input

7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?

Invalid Input

8. Trouble remembering important parts of the stressful experience?

Invalid Input

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)?

Invalid Input

10. Blaming yourself or someone else for the stressful experience or what happened after it?

Invalid Input

11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?

Invalid Input

12. Loss of interest in activities that you used to enjoy?

Invalid Input

13. Feeling distant or cut off from other people?

Invalid Input

14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?

Invalid Input

15. Irritable behaviour, angry outbursts, or acting aggressively?

Invalid Input

16. Taking too many risks or doing things that could cause you harm?

Invalid Input

17. Being "super alert" or watchful or on guard?

Invalid Input

18. Feeling jumpy or easily startled?

Invalid Input

19. Having difficulty concentrating?

Invalid Input

20. Trouble falling or staying asleep?

Invalid Input

Please verify you are human(*)

Invalid Input