INSTRUCTIONS: Below is a list of problems and complaints that people sometimes have in response to stressful life 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.

Full Name

The event you experienced was:

Date of event:

1. Repeated, disturbing memories, thoughts, or images of the stressful experience?

2. Repeated, disturbing dreams of the stressful experience?

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

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

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

6. Avoiding thinking about or talking about the stressful experience or avoiding having feelings related to it?

7. Avoiding activities or situations because they reminded you of the stressful experience?

8. Trouble remembering important parts of the stressful experience?

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

10. Feeling distant or cut off from other people?

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

12. Feeling as if your future will somehow be cut short?

13. Trouble falling or staying asleep?

14. Feeling irritable or having angry outbursts?

15. Having difficulty concentrating?

16. Being "super-alert" or watchful or on guard?

17. Feeling jumpy or easily startled?


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