Which office are you being treated in?* Toms River Freehold Name* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email* Today's Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920PTSD CHECKLIST FOR DSM-5 (PCL-5)Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem carefully and then select one of the numbers to indicate how much you have been bothered by that problem in the past month. 0 = Not at all 1 = A little bit 2 = Moderately 3 = Quite a bit 4 = ExtremelyIn the past month, how much were you bothered by:1. Repeated, disturbing, and unwanted memories of the stressful experience?* 0 1 2 3 4 2. Repeated, disturbing dreams of the stressful experience?* 0 1 2 3 4 3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?* 0 1 2 3 4 4. Feeling very upset when something reminded you of the stressful experience?* 0 1 2 3 4 5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?* 0 1 2 3 4 6. Avoiding memories, thoughts, or feelings related to the stressful experience?* 0 1 2 3 4 7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?* 0 1 2 3 4 8. Trouble remembering important parts of the stressful experience?* 0 1 2 3 4 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)?* 0 1 2 3 4 10. Blaming yourself or someone else for the stressful experience or what happened after it?* 0 1 2 3 4 11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?* 0 1 2 3 4 12. Loss of interest in activities that you used to enjoy?* 0 1 2 3 4 13. Feeling distant or cut off from other people?* 0 1 2 3 4 14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?* 0 1 2 3 4 15. Irritable behavior, angry outbursts, or acting aggressively?* 0 1 2 3 4 16. Taking too many risks or doing things that could cause you harm?* 0 1 2 3 4 17. Being “superalert” or watchful or on guard?* 0 1 2 3 4 18. Feeling jumpy or easily startled?* 0 1 2 3 4 19. Having difficulty concentrating?* 0 1 2 3 4 20. Trouble falling or staying asleep?* 0 1 2 3 4 Δ
