Traumatic Life Events Inventory and Posttraumatic Stress Disorder Checklist
Listed below are a number of difficult or stressful things that sometimes happen to people. For each event, circle one or more of the numbers to the right to indicate that: (a) it happened to you personally, (b) you witnessed it
happen to someone else, (c) you learned about it happening to someone close to you, (d) you’re not sure if it fits, or (e) it doesn’t apply to you.
Be sure to consider your entire life (growing up as well as adulthood) as you go through the list of events.
Event Happened to me Witnessed it about it Leaned Not sure Doesn’t apply
1. Natural disaster (for example, flood, hurricane, tornado,
earthquake) 0 1 2 3 4
2. Fire or explosion 0 1 2 3 4
3. Transportation accident (for example, car accident, boat
accident, train wreck, plane crash) 0 1 2 3 4
4. Serious accident at work, home, or during recreational activity 0 1 2 3 4
5. Exposure to toxic substance (for example, dangerous chemicals,
radiation) 0 1 2 3 4
6. Physical assault (for example, being attacked, hit, slapped, kicked, beaten up)
0 1 2 3 4
7.
Assault with a weapon (for example, being shot, stabbed, threatened with a knife, gun, bomb)
0 1 2 3 4
8.
Sexual assault (rape, attempted rape, made to perform any type of sexual act through force or threat of harm)
(continued)
Event Happened to me Witnessed it Leaned about it sure Not Doesn’t apply
10. Combat or exposure to a war-zone (in the military or as a
civilian) 0 1 2 3 4
11. Captivity (for example, being kidnapped, abducted, held hostage, prisoner of war)
0 1 2 3 4
12. Life-threatening illness or injury 0 1 2 3 4
13. Severe human suffering 0 1 2 3 4
14. Sudden, violent death (for
example, homicide, suicide) 0 1 2 3 4
15. Sudden unexpected death of
someone close to you 0 1 2 3 4
16. Serious injury, harm, or death you
caused to someone else 0 1 2 3 4
17. Any other very stressful event or
(continued)
If an event listed on the previous page happened to you, or you witnessed it, please complete the items below. If more than one event happened, please choose the one that is most troublesome to you now.
The event you experienced was:
__________________________________________________ on __________________
(Event) (Date)
Instructions
Below is a list of problems and complaints that people sometimes have in response to stressful life experiences. Please read each one carefully, then circle one of the numbers to the right to indicate how much you have been
bothered by the problem in the past month.
Bothered by Not at all A little bit Moderately Quite a bit Extremely
1. Repeated disturbing
memories, thoughts or images
of the stressful experience? 1 2 3 4 5
2. Repeated, disturbing dreams
of the stressful experience? 1 2 3 4 5
3. Suddenly acting or feeling as if the stressful experience were happening again? (As if you were reliving it?)
1 2 3 4 5
4. Feeling very upset when something reminded you of the stressful experience?
1 2 3 4 5
5. Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the stressful experience?
1 2 3 4 5
6. Avoiding thinking about or talking about the stressful experience or avoiding having feelings related to it.
1 2 3 4 5
7. Avoiding activities or
(continued)
Bothered by Not at all A little bit Moderately Quite a bit Extremely
8. Trouble remembering important parts of the
stressful experience? 1 2 3 4 5
9. Loss of interest in activities
that you used to enjoy? 1 2 3 4 5
10. Feeling distant or cut off from
other people? 1 2 3 4 5
11. Feeling emotionally numb or being unable to have loving feelings for those close to you?
1 2 3 4 5
12. Feeling as if your future will
somehow be cut short? 1 2 3 4 5
13. Trouble falling or staying
asleep? 1 2 3 4 5
14. Feeling irritable or having
angry outbursts? 1 2 3 4 5
15. Having difficulty
concentrating? 1 2 3 4 5
16. Being “super-alert” or
watchful or on guard? 1 2 3 4 5
17. Feeling jumpy or easily
startled? 1 2 3 4 5
Scoring
1) Was the person exposed to at least one event that involved actual or threatened death or serious injury, or threat to physical integrity of self or others? _____ YES
_____ NO
2) Did the person respond with intense fear, helplessness, or horror?
_____ YES _____ NO
3) Score of 44 or more? (add up all 17 items on the second page)
_____ YES _____ NO
If YES to all, PTSD:
_____ YES _____ NO Total Score: ____________________
Social Interaction Anxiety Scale
Instructions
In this section, for each item, please circle the number to indicate the degree to which you feel the statement is characteristic or true for you. The rating scale is as follows:
0 = Not at all characteristic or true of me. 1 = Slightly characteristic or true of me. 2 = Moderately characteristic or true of me. 3 = Very characteristic or true of me. 4 = Extremely characteristic or true of me
Characteristic Not at all Slightly Moderately Very Extremely
01. I get nervous if I have to speak with someone in authority (teacher, boss).
0 1 2 3 4
02. I have difficulty making eye
contact with others. 0 1 2 3 4
03. I become tense if I have to talk about myself or my feelings.
0 1 2 3 4
04. I find it difficult to mix comfortably with the people
I work with. 0 1 2 3 4
05. I find it easy to make friends
my own age. 0 1 2 3 4
06. I tense up if I meet an
acquaintance in the street. 0 1 2 3 4
07. When mixing socially, I am
uncomfortable. 0 1 2 3 4
08. I feel tense when I am alone
with just one person. 0 1 2 3 4
09. I am at ease meeting people
at parties, etc. 0 1 2 3 4
10. I have difficulty talking with
other people. 0 1 2 3 4
11. I find it easy to think of
(continued)
Characteristic Not at all Slightly Moderately Very Extremely
14. I have difficulty talking to attractive persons of the
opposite sex. 0 1 2 3 4
15. I find myself worrying that I won’t know what to say in
social situations. 0 1 2 3 4
16. I am nervous mixing with
people I don’t know well. 0 1 2 3 4
17. I feel I’ll say something
embarrassing when talking. 0 1 2 3 4
18. When mixing in a group, I find myself worrying I will
be ignored. 0 1 2 3 4
19. I am tense mixing in a
group. 0 1 2 3 4
20. I am unsure whether to greet someone I know only slightly.
0 1 2 3 4
Scoring
Total Score: Reserve Items: 5, 9, 11
Interpretation: 34+ Social Phobia is probable.
PATIENT HEALTH QUESTIONNAIRE (PHQ-9)
NAME: ______________________ DATE: ______________________
Over the last 2 weeks, how often have you been bothered by any of the following problems? (Use a check mark to indicate your answer)
Not at all Several days More than half the days Nearly every day
1. Little interest or pleasure in doing things 0 1 2 3 2. Feeling down, depressed, or hopeless 0 1 2 3 3. Trouble falling or staying asleep, or sleeping
too much
0 1 2 3
4. Feeling tired or having little energy 0 1 2 3 5. Poor appetite or overeating 0 1 2 3 6. Feeling bad about yourself – or that you are a
failure or have let yourself or your family down
0 1 2 3
7. Trouble concentrating on things, such as reading the newspaper or watching television
0 1 2 3
8. Moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual.
0 1 2 3
9. Thought that you would be better off dead, or of hurting yourself
0 1 2 3
add columns + + (Healthcare professional: For interpretation of TOTAL,
please refer to accompanying scoring card). TOTAL:
10. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Not difficult at all ___ Somewhat difficult ___ Very difficult ___ Extremely difficult ___
PHQ-9 Patient Depression Questionnaire For initial diagnosis:
Note: Since the questionnaire relies on patient self-report, all responses should be verified by the clinician, and a definitive diagnosis is made on clinical grounds taking into account how well the patient understood the
questionnaire, as well as other relevant information from the patient.
Diagnoses of Major Depressive Disorder or Other Depressive Disorder also require impairment of social,
occupational, or other important areas of functioning (Question #10) and ruling out normal bereavement, a history of a Manic Episode (Bipolar Disorder), and a physical disorder, medication, or other drug as the biological cause of the depressive symptoms.
To monitor severity over time for newly diagnosed patients or patients in current treatment for depression:
1. Patients may complete questionnaires at baseline and at regular intervals (eg, every 2 weeks) at home and bring them in at their next appointment for scoring or they may complete the questionnaire during each scheduled appointment.
2. Add up check marks by column. For every check mark: Several days = 1
More than half the days = 2 Nearly every day = 3
3. Add together column scores to get a TOTAL score.
4. Refer to the accompanying PHQ-9 Scoring Box to interpret the TOTAL score.
5. Results may be included in patient files to assist you in setting up a treatment goal, determining degree of response, as well as guiding treatment intervention.
Scoring: add up all checked boxes on PHQ-9 For every check mark:
Not at all = 0; Several days = 1; More than half the days = 2; Nearly every day = 3 Interpretation of Total Score
Total Score Depression Severity
1-4 Minimal depression 5-9 Mild depression 10-14 Moderate depression
15-19 Moderately severe depression 20-27 Severe depression
Patient Health Questionnaire (PHQ-2)
Over the past 2 weeks, have you often been bothered by: 1. Little interest or pleasure in doing things? [Yes] [No] 2. Feeling down, depressed, or hopeless? [Yes] [No]
If the patient responded “yes” to either question, follow up using the PHQ-9, a nine-item, self-administered questionnaire.
Primary Care PTSD Screen (PC-PTSD) Prins, Ouimette, & Kimerling, 2003
Description
The PC-PTSD is a 4-item screen that was designed for use in primary care and other medical settings and is currently used to screen for PTSD in veterans at the VA. The screen includes an introductory sentence to cue respondents to traumatic events. The authors suggest that in most circumstances the results of the PC-PTSD should be considered "positive" if a patient answers "yes" to any 3 items. Those screening positive should then be assessed with a structured interview for PTSD. The screen does not include a list of potentially traumatic events. In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you:
Have had nightmares about it or thought about it when you did not want to? YES / NO
Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? YES / NO
Were constantly on guard, watchful, or easily startled? YES / NO
Felt numb or detached from others, activities, or your surroundings? YES / NO
Current research suggests that the results of the PC-PTSD should be considered "positive" if a patient answers "yes" to any three items.
References
Prins, A., Ouimette, P., Kimerling, R., Cameron, R. P., Hugelshofer, D. S., Shaw-Hegwer, J., Thrailkill, A., Gusman, F.D., Sheikh, J. I. (2003). (PDF) The primary care PTSD screen (PC-PTSD): development and operating characteristics. Primary Care Psychiatry, 9, 9-14.
Prins, A., Ouimette, P., Kimerling, R., Cameron, R. P., Hugelshofer, D. S., Shaw-Hegwer, J., Thrailkill, A., Gusman, F.D., Sheikh, J. I. (2004). The primary care PTSD screen (PC-PTSD): Corrigendum. Primary Care Psychiatry, 9, 151.
Center for Epidemiologic Studies Depression Scale (CES-D), NIMH
Below is a list of the ways you might have felt or behaved. Please tell me how often you have felt this way during the past week.
During the Past Week
Rarely or none of the time (less than 1 day) Some or a little of the time (1-2 days) Occasionally or a moderate amount of time (3-4 days) Most or all of the time (5-7 days)
1. I was bothered by things that usually don’t bother me.
2. I did not feel like eating; my appetite was poor.
3. I felt that I could not shake off the blues even with help from my family or friends.
4. I felt I was just as good as other people. 5. I had trouble keeping my mind on what I
was doing. 6. I felt depressed.
7. I felt that everything I did was an effort. 8. I felt hopeful about the future.
9. I thought my life had been a failure. 10. I felt fearful.
11. My sleep was restless. 12. I was happy.
13. I talked less than usual. 14. I felt lonely.
15. People were unfriendly. 16. I enjoyed life.
17. I had crying spells. 18. I felt sad.
19. I felt that people dislike me. 20. I could not get “going.”