PTSD-M Form for Veterans

First Name *

Last Name *

Email *

Phone *

Checklist

INSTRUCTIONS: Below is a list of problems and complaints that veterans sometimes have in response to stressful military experiences. Please read each one carefully, then circle one of the numbers to the right to indicate how much you have been bothered by that problem in the past month.

Repeated, disturbing memories, thoughts, or images of a stressful military experience? *

Not at all

A little bit

Moderately

Quite a bit

Extremely

Repeated, disturbing dreams of a stressful military experience? *

Not at all

A little bit

Moderately

Quite a bit

Extremely

Suddenly acting or feeling as if a stressful military experience were happening again (as if you were reliving it)? *

Not at all

A little bit

Moderately

Quite a bit

Extremely

Feeling very upset when something reminded you of a stressful military experience? *

Not at all

A little bit

Moderately

Quite a bit

Extremely

Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of a stressful military experience? *

Not at all

A little bit

Moderately

Quite a bit

Extremely

Avoiding thinking about or talking about a stressful military experience or avoiding having feelings related to it? *

Not at all

A little bit

Moderately

Quite a bit

Extremely

Avoiding activities or situations because they reminded you of a stressful military experience? *

Not at all

A little bit

Moderately

Quite a bit

Extremely

Trouble remembering important parts of a stressful military experience? *

Not at all

A little bit

Moderately

Quite a bit

Extremely

Loss of interest in activities that you used to enjoy? *

Not at all

A little bit

Moderately

Quite a bit

Extremely

Feeling distant or cut off from other people? *

Not at all

A little bit

Moderately

Quite a bit

Extremely

Feeling emotionally numb or being unable to have loving feelings for those close to you? *

Not at all

A little bit

Moderately

Quite a bit

Extremely

Feeling as if your future will somehow be cut short? *

Not at all

A little bit

Moderately

Quite a bit

Extremely

Trouble falling or staying asleep? *

Not at all

A little bit

Moderately

Quite a bit

Extremely

Feeling irritable or having angry outbursts? *

Not at all

A little bit

Moderately

Quite a bit

Extremely

Having difficulty concentrating? *

Not at all

A little bit

Moderately

Quite a bit

Extremely

Being "super-alert" or watchful or on guard? *

Not at all

A little bit

Moderately

Quite a bit

Extremely

Feeling jumpy or easily startled? *

Not at all

A little bit

Moderately

Quite a bit

Extremely

PCL-M for DSM-IV (11/1/94) Weathers, Litz, Huska, & Keane National Center for PTSD - Behavioral Science Division