PCL-5 ANXIETY/DEPRESSION SCALE (0-not at all) (1-a little bit) (2-Moderately) (3- Quite a Bit) (4-Extremely)
In the past month, how much were you bothered by:
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Email *
NAME & DATE OF BIRTH *
Repeated, disturbing, and unwanted memories of the stressful experience? *
(0-NOT AT ALL) (1- A LTTLE BIT) (2-MODERATELY) (3-QUITE A BIT)
(EXTREMELY)
Repeated, disturbing, dreams of the stressful experience? *
NOT AT ALL (1- A LTTLE BIT) (2-MODERATELY) (3-QUITE A BIT)
(EXTREMELY)
Suddenly feeling or acting as if the stressful experience were actually happening again-( as if you were actually back there reliving it) ? *
NOT AT ALL (1- A LTTLE BIT) (2-MODERATELY) (3-QUITE A BIT)
(EXTREMELY)
Feeling very upset when something reminded you of the stressful experience? *
NOT AT ALL (1- A LTTLE BIT) (2-MODERATELY) (3-QUITE A BIT)
(EXTREMELY)
Having strong physical reactions when something reminded you of the stressful experience- ( for example, heart pounding, trouble breathing, sweating)? *
NOT AT ALL (1- A LTTLE BIT) (2-MODERATELY) (3-QUITE A BIT)
(EXTREMELY)
Avoiding memories, thoughts, or feelings related to this stressful experience? *
NOT AT ALL (1- A LTTLE BIT) (2-MODERATELY) (3-QUITE A BIT)
(EXTREMELY)
Avoiding external reminders of the stressful experience( for example, people, places, conversations, activities, objects, situations)? *
NOT AT ALL (1- A LTTLE BIT) (2-MODERATELY) (3-QUITE A BIT)
(EXTREMELY)
Trouble, remembering the important parts of the stressful experience? *
NOT AT ALL (1- A LTTLE BIT) (2-MODERATELY) (3-QUITE A BIT)
(EXTREMELY)
Having a strong negative beliefs about your self, 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’s completely dangerous)? *
NOT AT ALL (1- A LTTLE BIT) (2-MODERATELY) (3-QUITE A BIT)
(EXTREMELY)
Blaming yourself or someone else for the stressful experience or what happened after it? *
NOT AT ALL (1- A LTTLE BIT) (2-MODERATELY) (3-QUITE A BIT)
(EXTREMELY)
Having strong negative feelings, such as fear, horror, anger, guilt, or shame? *
NOT AT ALL (1- A LTTLE BIT) (2-MODERATELY) (3-QUITE A BIT)
(EXTREMELY)
Loss of interest in activities that you used to enjoy? *
NOT AT ALL (1- A LTTLE BIT) (2-MODERATELY) (3-QUITE A BIT)
(EXTREMELY)
Feeling distant or cut off from other people? *
NOT AT ALL (1- A LTTLE BIT) (2-MODERATELY) (3-QUITE A BIT)
(EXTREMELY)
Trouble experiencing positive feelings,( for example, being unable to feel happiness, or have a loving feelings for people close to you)? *
NOT AT ALL (1- A LTTLE BIT) (2-MODERATELY) (3-QUITE A BIT)
(EXTREMELY)
Irritable behavior, angry outburst, or acting aggressively? *
NOT AT ALL (1- A LTTLE BIT) (2-MODERATELY) (3-QUITE A BIT)
(EXTREMELY)
Taking too many risk, or doing things that could cause you harm? *
NOT AT ALL (1- A LTTLE BIT) (2-MODERATELY) (3-QUITE A BIT)
(EXTREMELY)
Being “super alert” or watchful or on guard? *
NOT AT ALL (1- A LTTLE BIT) (2-MODERATELY) (3-QUITE A BIT)
(EXTREMELY)
Feeling jumpy, or easily startled? *
NOT AT ALL (1- A LTTLE BIT) (2-MODERATELY) (3-QUITE A BIT)
(EXTREMELY)
Having difficulty concentrating? *
NOT AT ALL (1- A LTTLE BIT) (2-MODERATELY) (3-QUITE A BIT)
(EXTREMELY)
Trouble falling or staying asleep? *
NOT AT ALL (1- A LTTLE BIT) (2-MODERATELY) (3-QUITE A BIT)
(EXTREMELY)
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