PTSD Symptom Checklist
Please complete this checklist to help assess symptoms related to post-traumatic stress. Your responses are confidential and will assist in understanding your experiences.
Full Name
*
First Name
Last Name
Age
*
Gender
Male
Female
Non-binary
Prefer not to say
Other
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
In the past month, how often have you experienced the following symptoms?
*
Rows
Not at all
Once or twice
2-4 times a week
Nearly every day
Repeated, disturbing memories, thoughts, or images of a stressful experience from the past?
1
2
3
4
Avoiding activities or situations because they remind you of a stressful experience from the past?
5
6
7
8
Feeling distant or cut off from other people?
9
10
11
12
Feeling irritable or having angry outbursts?
13
14
15
16
Being "super alert" or watchful on guard?
17
18
19
20
Trouble falling or staying asleep?
21
22
23
24
Feeling emotionally numb or unable to have loving feelings for those close to you?
25
26
27
28
Trouble concentrating or paying attention?
29
30
31
32
How would you rate the overall impact of these symptoms on your daily life?
*
No impact
1
2
3
4
5
6
7
8
9
Severe impact
10
1 is No impact, 10 is Severe impact
How long have you been experiencing these symptoms?
*
Please Select
Less than 1 month
1-3 months
3-6 months
More than 6 months
Have you ever received a diagnosis of PTSD from a healthcare professional?
Yes
No
Not sure
Is there anything else you would like to share about your symptoms or experiences?
Submit Checklist
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