PCL-5 PTSD Contact Information*Resolutions Professional Counseling, PLLC Tara Fleis, LPC tfleis@resolutionsprofessionalcounseling.com 906-282-3130 9885 State Hwy. M95, Republic, MI 49879 308 Cleveland Ave. Ste. 302, Ishpeming, MI 49849 Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Instructions:Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem carefully and then circle one of the numbers to the right to indicate how much you have been bothered by that problem in the past month. In the past month, how much were you bothered by: Not at all = 0 | A little bit = 1 Moderately = 2 Quite a bit = 3 Extremely = 41. Repeated, disturbing, and unwanted memories of the stressful experience?*0 - Not at all1 - A little bit2 - Moderately3 - Quite a bit4 - Extremely2. Repeated, disturbing dreams of the stressful experience?*0 - Not at all1 - A little bit2 - Moderately3 - Quite a bit4 - Extremely3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?*0 - Not at all1 - A little bit2 - Moderately3 - Quite a bit4 - Extremely4.Feeling very upset when something reminded you of the stressful experience?*0 - Not at all1 - A little bit2 - Moderately3 - Quite a bit4 - Extremely5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?*0 - Not at all1 - A little bit2 - Moderately3 - Quite a bit4 - Extremely6. Avoiding memories, thoughts, or feelings related to the stressful experience?*0 - Not at all1 - A little bit2 - Moderately3 - Quite a bit4 - Extremely7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?*0 - Not at all1 - A little bit2 - Moderately3 - Quite a bit4 - Extremely8. Trouble remembering important parts of the stressful experience?*0 - Not at all1 - A little bit2 - Moderately3 - Quite a bit4 - Extremely9. 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)?*0 - Not at all1 - A little bit2 - Moderately3 - Quite a bit4 - Extremely10. Blaming yourself or someone else for the stressful experience or what happened after it?*0 - Not at all1 - A little bit2 - Moderately3 - Quite a bit4 - Extremely11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?*0 - Not at all1 - A little bit2 - Moderately3 - Quite a bit4 - Extremely12. Loss of interest in activities that you used to enjoy?*0 - Not at all1 - A little bit2 - Moderately3 - Quite a bit4 - Extremely13. Feeling distant or cut off from other people?*0 - Not at all1 - A little bit2 - Moderately3 - Quite a bit4 - Extremely14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?*0 - Not at all1 - A little bit2 - Moderately3 - Quite a bit4 - Extremely15. Irritable behavior, angry outbursts, or acting aggressively?*0 - Not at all1 - A little bit2 - Moderately3 - Quite a bit4 - Extremely16. Taking too many risks or doing things that could cause you harm?*0 - Not at all1 - A little bit2 - Moderately3 - Quite a bit4 - Extremely17. Being “superalert” or watchful or on guard?*0 - Not at all1 - A little bit2 - Moderately3 - Quite a bit4 - Extremely18. Feeling jumpy or easily startled?*0 - Not at all1 - A little bit2 - Moderately3 - Quite a bit4 - Extremely19. Having difficulty concentrating?*0 - Not at all1 - A little bit2 - Moderately3 - Quite a bit4 - Extremely20. Trouble falling or staying asleep?*0 - Not at all1 - A little bit2 - Moderately3 - Quite a bit4 - ExtremelyClient Signature*Type your full nameDate* Date Format: MM slash DD slash YYYY