| RPT |
.|.|PTSD Checklist Stressor Specific||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB:
IMPORTANT PARTS of the stressful experience?| <*Answer_5167*>|9. LOSS of INTEREST in activities that you used to enjoy?| <*Answer_5168*>|10. Feeling DISTANT or CUT OFF from other people?|
<*Answer_5169*>|11. Feeling EMOTIONALLY NUMB or being unable to have loving feelings for those close to you?| <*Answer_5170*>|12. Feeling as if your FUTURE somehow will be CUT SHORT?|
<*Answer_5171*>|13. Trouble FALLING or STAYING ASLEEP?| <*Answer_5172*>|14. Feeling IRRITABLE or having ANGRY OUTBURSTS?| <*Answer_5173*>|15. Having DIFFICULTY CONCENTRATING?|
<*Answer_5174*>|16. Being "SUPERALERT" or watchful or on guard?| <*Answer_5175*>|17. Feeling JUMPY or easily startled?| <*Answer_5176*>|||Information contained in this note is based on a
self-report assessment and is not sufficient to use alone for diagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and
procedures.| $~
<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||PCLS Score: <-Score->||The score has a range of 17 to 85. A cutoff score is relevant to these populations.| VA PTSD
specialty mental health clinic: Screening-48 Diagnosis-56 | VA primary care clinic: Screening-25 Diagnosis-33 | Active duty Iraq/Afghanistan (OEF/OIF) Screening-25 Diagnosis-28 | Civilian
substance abuse residential: Screening-36 Diagnosis-44 | Civilian primary care: Screening-25 Diagnosis-30-38 | Civilian motor vehicle accidents: Screening-44 Diagnosis-50||Questions and
Answers||A. The event you experienced was:| <*Answer_5158*>|B. Date of the event:| <*Answer_5159*>|1. Repeated disturbing MEMORIES, THOUGHTS or IMAGES of the stressful experience?|
<*Answer_5160*>|2. Repeated disturbing DREAMS of the stressful experience?| <*Answer_5161*>|3. Suddenly ACTING or FEELING as if the stressful experience from the past were happening again (as if
you were reliving it)?| <*Answer_5162*>|4. Feeling VERY UPSET when SOMETHING reminded you of the stressful experience?| <*Answer_5163*>|5. Having PHYSICAL reactions (e.g. heart pounding,
trouble breathing, sweating) when SOMETHING REMINDED you of the stressful experience?| <*Answer_5164*>|6. Avoiding THINKING ABOUT or TALKING ABOUT the stressful experience from the past or
AVOIDING HAVING FEELINGS related to it?| <*Answer_5165*>|7. Avoiding ACTIVITIES or SITUATIONS because they REMINDED you of the stressful experience?| <*Answer_5166*>|8. Trouble REMEMBERING
|
