Name *

First Name

Last Name

Repeated, disturbing memories, thoughts, or images of a stressful experience? *

Yes

No

Repeated, disturbing dreams of a stressful experience? *

Yes

No

Suddenly acting or feeling as if a stressful experience were happening again( as if you were reliving it)? *

Yes

No

Feeling very upset when something reminds you of a stressful experience? *

Yes

No

Having physical reactions(e.g., heart pounding, trouble breathing, sweating) when something reminds you of a stressful experience? *

Yes

No

Avoiding thinking about or talking about a stressful experience or avoiding having feelings related to it? *

Yes

No

Avoiding activities or situations because they remind you of a stressful experience? *

Yes

No

Trouble remembering important parts of a stressful experience? *

Yes

No

Loss of interest of activities that you used to enjoy? *

Yes

No

Feeling distant or cut off from other other people? *

Yes

No

Feeling emotionally numb or being unable to have loving feelings for those close to you? *

Yes

No

Feeling as if your future will somehow be cut short? *

Yes

No

Trouble falling or staying asleep? *

Yes

No

Feeling irritable or having angry outbursts? *

Yes

No

Having difficulty concentrating? *

Yes

No

Being very watchful or on guard? *

Yes

No

Easily startled or jumpy? *

Yes

No