PTSD and Anxiety Questionnaire

Instructions: Below is a list of problems and complaints that people with PTSD sometimes have in response to stressful life experiences. Please read each one carefully and check the appropriate box to indicate how much you have been bothered by that problem in the past month.

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    1. Repeated, disturbing memories, thoughts, or images of a stressful experience from the past?Not at allA little bitModeratelyQuite a bitExtremely
    2. Repeated, disturbing dreams of a stressful experience from the past? Not at allA little bitModeratelyQuite a bitExtremely
    3. Suddenly acting or feeling as if a stressful experience were happening again (as if you were reliving it)?Not at allA little bitModeratelyQuite a bitExtremely
    4. Feeling very upset when something reminded you of a stressful experience from the past?Not at allA little bitModeratelyQuite a bitExtremely
    5. Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of a stressful experience from the past?Not at allA little bitModeratelyQuite a bitExtremely
    6. Avoiding thinking about or talking about a stressful experience from the past or avoiding having feelings related to it?Not at allA little bitModeratelyQuite a bitExtremely
    7. Avoiding activities or situations because they reminded you of a stressful experience from the past?
    Not at allA little bitModeratelyQuite a bitExtremely
    8. Trouble remembering important parts of a stressful experience from the past?Not at allA little bitModeratelyQuite a bitExtremely
    9. Loss of interest in activities that you used to enjoy?Not at allA little bitModeratelyQuite a bitExtremely
    10. Feeling distant or cut off from other people?Not at allA little bitModeratelyQuite a bitExtremely
    11. Feeling emotionally numb or being unable to have loving feelings for those close to you?Not at allA little bitModeratelyQuite a bitExtremely
    12. Feeling as if your future will somehow be cut short?Not at allA little bitModeratelyQuite a bitExtremely
    13. Trouble falling or staying asleep?Not at allA little bitModeratelyQuite a bitExtremely
    14. Feeling irritable or having angry outbursts?Not at allA little bitModeratelyQuite a bitExtremely
    15. Having difficulty concentrating?Not at allA little bitModeratelyQuite a bitExtremely
    16. Being "super-alert" or watchful or on guard?Not at allA little bitModeratelyQuite a bitExtremely
    17. Feeling jumpy or easily startled?Not at allA little bitModeratelyQuite a bitExtremely
    18. Feeling Nervous, anxious or on edgeNot at allSeveral daysMore than half the daysNearly every day
    19. Not being able to stop or control worryingNot at allA little bitModeratelyQuite a bitExtremely
    20. Worrying too much about different thingsNot at allA little bitModeratelyQuite a bitExtremely
    21. Trouble relaxingNot at allSeveral daysMore than half the daysNearly every day
    22. Being so restless that it is hard to sit stillNot at allA little bitModeratelyQuite a bitExtremely
    23. Becoming easily annoyed or irritableNot at allSeveral daysMore than half the daysNearly every day
    24. Feeling afraid, as if something awful might happenNot at allA little bitModeratelyQuite a bitExtremely
    25. If you checked any problems, how difficult have they made it for you to do your work, take care of things at home, or get along with other people?Not difficult at allSomewhat difficultVery difficultExtremely difficult
    26. Have you had a traumatic experience?YesNo
    27. Do you have a mental health diagnosis?YesNo
    If yes, are you currently under the care of a behavioral health professional or physician?
    28. Are you currently taking any medication?YesNo
    If yes, please list
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