PTSD CheckList – Civilian Version (PCL-C)

PTSD CheckList – Civilian Version (PCL-C)
Unique Identifier
Date
MonthDayYear
PCL-C
Instruction to patient: Below is a list of problems and complaints that people sometimes have in response to stressful life experiences. Please read each one carefully and click on the box to indicate how much you have been bothered by that problem in the last month.
(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, or sweating) when something reminded you of a stressful experience from the past?*
Not at allA little bitModeratelyQuite a bitExtremely
(6) Avoid thinking about or talking about a stressful experience from the past or avoid having feelings related to it? *
Not at allA little bitModeratelyQuite a bitExtremely
(7) Avoid activities or situations because they remind 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 things 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 on guard?*
Not at allA little bitModeratelyQuite a bitExtremely
(17) Feeling jumpy or easily startled?*
Not at allA little bitModeratelyQuite a bitExtremely
How is the PCL Scored?
1) Add up all items for a total severity score: Low = 17 - 35, Moderate 36 - 44, High 45+ (VA Scores)
or
2) Treat response categories 3–5 (Moderately or above) as symptomatic and responses 1–2 (below Moderately) as non-symptomatic, then use the following DSM criteria for a diagnosis:
Re-experiencing, Avoidance & Hyperarrousal.
Score
Should be Empty: