Carly DeCotiis, MA, NCC, LPC, ACS, CCS

                                                                                                          Trauma questionnaire 

Listed below are a number of difficult or stressful things that sometimes happen to people. For each event check one or more of the boxes 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 a close family member or close friend; (d) you were exposed to it as part of your job (for example, paramedic, police, military, or other first responder); (e) you’re not sure if it fits; or (f) 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    Learned about it  Part of my job    Not sure      Doesn't Apply_____

1. Natural Disaster (flood, hurricane, tornado, earthquake, fire)

_________________________________________________________________________________________________

2. Transportation accident ( car/boat/plane/accident etc)

__________________________________________________________________________________________________

3. Serious accident at work, home or during recreational activity 

__________________________________________________________________________________________________

4. Physical assault ( being attacked, hit, slapped, kicked, beaten up etc)

__________________________________________________________________________________________________

5. Assault with a weapon ( shot, stabbed, threatened with a knife, gun etc)

__________________________________________________________________________________________________

6. Sexual assault (rape, attempted rape, made to perform any type of sexual act through force or threat of harm)

__________________________________________________________________________________________________

7. Other unwanted or uncomfortable sexual experience 

__________________________________________________________________________________________________

8. Combat or exposure to war (in the military or a civilian)

__________________________________________________________________________________________________

9. Life-threatening illness or injury 

__________________________________________________________________________________________________

10. Severe human suffering 

__________________________________________________________________________________________________

11. Sudden violet/accidental death

__________________________________________________________________________________________________

12. Any other stressful event or experience 

__________________________________________________________________________________________________

LEC-5 (10/27/2013) Weathers, Blake, Schnurr, Kaloupek, Marx, & Keane -- National Center for PTSD


                                                                   PTSD questionnaire 

Below is a list of problems and complaints that people sometimes have in response to stressful life experiences. Put an "X" in the box to indicate how much you have been bothered by that problem in the LAST MONTH


Response                       Not at all                  A little bit                         Moderately                       Quite a bit                          Extremely__

1. Repeated, disturbing memories, thoughts, or images of a stressful experience from the past?

__________________________________________________________________________________________________

2. Repeated, disturbing dreams of a stressful experience from the past?

__________________________________________________________________________________________________

3. Suddenly acting or feeling as if a stressful experience were happening again (as if you were reliving it)?

__________________________________________________________________________________________________

4. Feeling very upset when something reminded you of a stressful experience from the past?

__________________________________________________________________________________________________

5. Having physical reactions (i.e. heart pounding, trouble breathing or sweating) when something reminded you of a stressful experience from the past?

__________________________________________________________________________________________________

6. Avoid thinking about or talking about a stressful experience from the past or avoid having feelings related to it?

__________________________________________________________________________________________________

7. Avoid activities or situations because they remind you of a stressful experience from the past?

__________________________________________________________________________________________________

8. Trouble remembering important parts of a stressful experience from the past?

__________________________________________________________________________________________________

9. Loss of interest in things that you used to enjoy?

__________________________________________________________________________________________________

10. Feeling distant or cut off from other people?

__________________________________________________________________________________________________

11. Feeling emotionally numb or being unable to have loving feelings for those close to you?

__________________________________________________________________________________________________

12. Feeling as if your future will somehow be cut short?

__________________________________________________________________________________________________

13. Trouble falling or staying asleep?

__________________________________________________________________________________________________

14. Feeling irritable or having angry outbursts?

__________________________________________________________________________________________________

15. Having difficulty concentrating?

_________________________________________________________________________________________________

16. Being "super alert" or watchful on guard?

__________________________________________________________________________________________________

17. Feeling jumpy or easily startled?

__________________________________________________________________________________________________

Weathers, F.W., Huska, J.A., Keane, T.M. PCL-C for DSM-IV. Boston: National Center for PTSD – Behavioral Science Division, 1991.