| RPT |
|PCL-5 DAILY (PCL-5 DAILY)
| Gender: <.Patient_Gender.>
|
| PCL-5 DAILY Total Score = <-PCL-5 DAILY->
|
| 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.
|
|Questions and Answers:
|
| Date Given: <.Date_Given.>
| 1. Repeated, disturbing, and unwanted memories of the stressful
| experience?
| <*Answer_9230*>
| 2. Repeated, disturbing dreams of the stressful experience?
| <*Answer_9231*>
| 3. Suddenly feeling or acting as if the stressful experience were
| actually happening again (as if you were actually back there
| reliving it)?
| <*Answer_9232*>
| 4. Feeling very upset when something reminded you of the stressful
| Clinician: <.Staff_Ordered_By.>
| experience?
| <*Answer_9233*>
| 5. Having strong physical reactions when something reminded you of the
| stressful experience (for example, heart pounding, trouble breathing,
| sweating)?
| <*Answer_9234*>
| 6. Avoiding memories, thoughts, or feelings related to the stressful
| experience?
| <*Answer_9235*>
| 7. Avoiding external reminders of the stressful experience (for example,
| Location: <.Location.>
| people, places, conversations, activities, objects, or situations)?
| <*Answer_9236*>
| 8. Trouble remembering important parts of the stressful experience?
| <*Answer_9237*>
| 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_9238*>
| 10. Blaming yourself or someone else for the stressful experience or what
|
| happened after it?
| <*Answer_9239*>
| 11. Having strong negative feelings such as fear, horror, anger, guilt, or
| shame?
| <*Answer_9240*>
| 12. Loss of interest in activities that you used to enjoy?
| <*Answer_9241*>
| 13. Feeling distant or cut off from other people?
| <*Answer_9242*>
| 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_9243*>
| 15. Irritable behavior, angry outbursts, or acting aggressively?
| <*Answer_9244*>
| 16. Taking too many risks or doing things that could cause you harm?
| <*Answer_9245*>
| 17. Being "super alert" or watchful or on guard?
| <*Answer_9246*>
| 18. Feeling jumpy or easily startled?
| <*Answer_9247*>
| SSN: <.Patient_SSN.>
| 19. Having difficulty concentrating?
| <*Answer_9248*>
| 20. Trouble falling or staying asleep?
| <*Answer_9249*>
|
|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.
| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
|
