| RPT |
PCL-5 WEEKLY
| Gender: <.Patient_Gender.>
|
|
| PCL-5 Weekly Score: <-PCL-5->
|
| This measure assesses an individual's perception of the distress associated
| with possible PTSD symptoms. It is not used to diagnose PTSD. Symptoms are
| rated from 0-4 in terms of distress they cause the individual. Scores that
| are greater than or equal to 31-33 suggest that the veteran may meet the
| criteria for a PTSD diagnosis. However, it is important to use caution when
|
| using this cutoff since it is possible for some Veterans with scores lower
| than 31-33 to meet criteria for PTSD.
|
| Additional testing using a structured diagnostic interview, such as the
| Clinician Administered PTSD Scale for DSM-5, is recommended to confirm
| diagnostic status.
|
| Values range from 0 to 80 with higher scores indicating more probable PTSD.
|
|
| Date Given: <.Date_Given.>
| Questions and Answers:
|
| 1. Repeated, disturbing, and unwanted memories of the stressful experience?
| <*Answer_7855*>
| 2. Repeated, disturbing dreams of the stressful experience?
| <*Answer_7856*>
| 3. Suddenly feeling or acting as if the stressful experience were actually
| happening again (as if you were actually back there reliving it)?
| <*Answer_7857*>
| 4. Feeling very upset when something reminded you of the stressful
| Clinician: <.Staff_Ordered_By.>
| experience?
| <*Answer_7858*>
| 5. Having strong physical reactions when something reminded you of the
| stressful experience (for example, heart pounding, trouble breathing,
| sweating)?
| <*Answer_7859*>
| 6. Avoiding memories, thoughts, or feelings related to the stressful
| experience?
| <*Answer_7860*>
| 7. Avoiding external reminders of the stressful experience (for example,
| Location: <.Location.>
| people, places, conversations, activities, objects, or situations)?
| <*Answer_7861*>
| 8. Trouble remembering important parts of the stressful experience?
| <*Answer_7862*>
| 9. Having strong negative beliefs about yourself, other people, or the
| world (for example, having thoughts such as: I am bad, there is
| something seriously wrong with me, no one can be trusted, the world is
| completely dangerous)?
| <*Answer_7863*>
| 10. Blaming yourself or someone else for the stressful experience or what
|
| happened after it?
| <*Answer_7864*>
| 11. Having strong negative feelings such as fear, horror, anger, guilt, or
| shame?
| <*Answer_7865*>
| 12. Loss of interest in activities that you used to enjoy?
| <*Answer_7866*>
| 13. Feeling distant or cut off from other people?
| <*Answer_7867*>
| 14. Trouble experiencing positive feelings (for example, being unable to
| Veteran: <.Patient_Name_Last_First.>
| feel happiness or have loving feelings for people close to you)?
| <*Answer_7868*>
| 15. Irritable behavior, angry outbursts, or acting aggressively?
| <*Answer_7869*>
| 16. Taking too many risks or doing things that could cause you harm?
| <*Answer_7870*>
| 17. Being "superalert" or watchful or on guard?
| <*Answer_7871*>
| 18. Feeling jumpy or easily startled?
| <*Answer_7872*>
| SSN: <.Patient_SSN.>
| 19. Having difficulty concentrating?
| <*Answer_7873*>
| 20. Trouble falling or staying asleep?
| <*Answer_7874*>
|
| 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.
| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
|
