Post Traumatic Stress Disorder Questionnaire

1. Did you experience a traumatic event in which the following was present:
 
1.1 You experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of yourself or others
  No   Yes
 
1.2 Your response involved intense fear, helplessness or horror.
  No   Yes
 
2. Do you re-experience the event persistently in one of the following ways:
 
2.1 Recurrent and intrusive distressing recollections of the event, including images, thoughts or perceptions
  No   Yes
 
2.2 Recurrent distressing dreams of the event
  No   Yes
 
2.3 Acting or feeling as if the traumatic events were recurring (including a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated)
  No   Yes
 
2.4 Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of traumatic event
  No   Yes
 
2.5 Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of traumatic event
  No   Yes
 
3. Do you persistently avoid any of the following situations associated with the trauma (Not present before the trauma)
 
3.1 Thoughts, feelings, or conversations associated with the trauma
  No   Yes
 
3.2 Activities, places, or people that arouse recollections of the trauma
  No   Yes
 
3.3 Inability to recall an important aspect of the trauma
  No   Yes
 
3.4 Markedly diminished interest or participation in significant activities
  No   Yes
 
3.5 Feeling of detachment or estrangement from others
  No   Yes
 
3.6 Restricted range of affect (e.g., unable to have loving feelings)
  No   Yes
 
3.7 Sense of a foreshortened future (e.g., does not expect to have a career, marraige, children, or a normal life span)
  No   Yes
 
4. Persistent symptoms of increased arousal (not present before the trauma)
 
4.1 Difficulty falling or staying asleep
  No   Yes
 
4.2 Irritability or outbursts of anger
  No   Yes
 
4.3 Difficulty concentrating
  No   Yes
 
4.4 Hypervigilance
  No   Yes
 
4.5 Exaggerated startle response
  No   Yes
 
5. How long has these symptoms persisted?
  Less that 1 month   Less that 3 months   More that 3 months
 
6. How long after the event did the symptoms start
  Immediately   1 month   3 month   6 months or more
     

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