| Name | Value |
|---|---|
| REPORT NUMBER | 155 |
| INSTRUMENT | PC-PTSD-5+I9 |
| RPT | | | PC-PTSD-5+PHQ Item9 (PC-PTSD-5+I9)
| PC PTSD-5+I9 PTSD Screen: <*Answer_7776*>| <*Answer_7771*>|<*Answer_7772*>|
| PC PTSD-5+I9 Suicide Screen: <*Answer_7777*>| <*Answer_7773*>|<*Answer_7774*>| |
Questions and Answers|
Sometimes things happen to people that are unusually or especially|
frightening, horrible, or traumatic. For example:||
A serious accident or fire|
A physical or sexual assault or abuse|
An earthquake or flood|
| Date Given: <.Date_Given.>
A war|
Seeing someone be killed or seriously injured|
Having a loved one die through homicide or suicide||
Have you ever experienced this kind of event?| <*Answer_7822*>||
1. Had nightmares about the event(s) when you did not want to?| <*Answer_7823*>|
2. Tried hard not to think about the event(s) or went out of your way to|
avoid situations that remind you of the event(s)?| <*Answer_7824*>|
3. Been constantly on guard, watchful, or easily startled?| <*Answer_7825*>|
4. Felt numb or detached from people, activities, or your surroundings?| <*Answer_7826*>|
| Clinician: <.Staff_Ordered_By.>
5. Felt guilty or unable to stop blaming yourself or others for the|
event(s) or any problems the event(s) may have caused?| <*Answer_7828*>|
6. Over the last 2 weeks, how often have you been bothered by thoughts |
that you would be better off dead or of hurting yourself in some way?| <*Answer_7829*>|
| |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.
| Location: <.Location.>
| |PC-PTSD-5, 2015, National Center for PTSD
$~
| | Veteran: <.Patient_Name_Last_First.>
| SSN: <.Patient_SSN.>
| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
| Gender: <.Patient_Gender.>| |
|