| RPT |
.|.|PTSD Checklist Stressor Specific||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB:
<*Answer_5412*>|13. Trouble FALLING or STAYING ASLEEP?| <*Answer_5413*>|14. Feeling IRRITABLE or having ANGRY OUTBURSTS?| <*Answer_5414*>|15. Having DIFFICULTY CONCENTRATING?|
<*Answer_5415*>|16. Being "SUPERALERT" or watchful or on guard?| <*Answer_5416*>|17. Feeling JUMPY or easily startled?| <*Answer_5417*>|18. How difficult have these problems made it for you to
do your work, take care of things at home, or get along with other people?| <*Answer_5418*>|19. During the last two weeks have you had thoughts that you would be better off dead, or of hurting
yourself in some way?| <*Answer_5419*>| 19A. How often have you had these thoughts?| <*Answer_5420*>|||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.>| |PCL-SZ Score: <-Score->|| Range 0-68. A high score indicates PTSD symptoms are endorsed.||Questions and Answers||A. The
event you experienced was:| <*Answer_5399*>|B. When did the event occur:| <*Answer_5433*>||1. Repeated disturbing MEMORIES, THOUGHTS or IMAGES of the stressful experience?|
<*Answer_5401*>|2. Repeated disturbing DREAMS of the stressful experience?| <*Answer_5402*>|3. Suddenly ACTING or FEELING as if the stressful experience from the past were happening again (as if
you were reliving it)?| <*Answer_5403*>|4. Feeling VERY UPSET when SOMETHING reminded you of the stressful experience?| <*Answer_5404*>|5. Having PHYSICAL reactions (e.g. heart pounding,
trouble breathing, sweating) when SOMETHING REMINDED you of the stressful experience?| <*Answer_5405*>|6. Avoiding THINKING ABOUT or TALKING ABOUT the stressful experience from the past or
AVOIDING HAVING FEELINGS related to it?| <*Answer_5406*>|7. Avoiding ACTIVITIES or SITUATIONS because they REMINDED you of the stressful experience?| <*Answer_5407*>|8. Trouble REMEMBERING
IMPORTANT PARTS of the stressful experience?| <*Answer_5408*>|9. LOSS OF INTEREST in activities that you used to enjoy?| <*Answer_5409*>|10. Feeling DISTANT or CUT OFF from other people?|
<*Answer_5410*>|11. Feeling EMOTIONALLY NUMB or being unable to have loving feelings for those close to you?| <*Answer_5411*>|12. Feeling as if your FUTURE somehow will be CUT SHORT?|
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