• PTSD Checklist (PCL) - 5

    PTSD Checklist (PCL) - 5

  • Client Date of Birth*
     - -
  • Today's Date
     - -
  • Stage of Treatment*
  • In what setting do you receive services? check all that apply:

  • 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. 

     

  • For below questions 

    In the past month, how much were you bothered by: 

  • 1. Repeated, disturbing, and unwanted memories of the stressful experience?
  • 2. Repeated, disturbing dreams of the stressful experience?
  • 3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
  • 4. Feeling very upset when something reminded you of the stressful experience?
  • 5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?
  • 6. Avoiding memories, thoughts, or feelings related to the stressful experience?
  • 7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?
  • 8. Trouble remembering important parts of the stressful experience?
  • 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)?
  • 10. Blaming yourself or someone else for the stressful experience or what happened after it?
  • 11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?
  • 12. Loss of interest in activities that you used to enjoy?
  • 13. Feeling distant or cut off from other people?
  • 14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
  • 15. Irritable behavior, angry outbursts, or acting aggressively?
  • 16. Taking too many risks or doing things that could cause you harm?
  • 17. Being “super alert” or watchful or on guard?
  • 18. Feeling jumpy or easily startled?
  • 19. Having difficulty concentrating?
  • 20. Trouble falling or staying asleep?
  • Date
     - -

  • When given at an intake or assessment session, the PCL-5 may be used to help determine the appropriate next steps or treatment options.

    For example:

    • A total score of 33 or higher suggests the patient may need to “step up” in their level of PTSD care – either be referred to a PTSD specialty clinic or offered an evidence-based treatment for PTSD such as Prolonged Exposure (PE) or Cognitive Processing Therapy (CPT).
    • Scores lower than 33 may indicate the patient either has subthreshold symptoms of PTSD or
      does not meet criteria for PTSD, and this information should be incorporated into treatment
      planning.

  • Should be Empty: