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Instructions: Please think of experience that troubles you most and answer the following questions in specific relation to this experience. Please read each item carefully, then indicate how much you have been bothered by that problem in the PAST MONTH.

Having upsetting dreams that replay part of the experience or are clearly related to the experience? Required
Having powerful images or memories that sometimes come into your mind in which you feel the experience is happening again in the here and now? Required
Avoiding internal reminders of the experience (for example, thoughts, feelings, or physical sensations)? Required
Avoiding external reminders of the experience (for example, people, places, conversations, objects, activities, or situations)? Required
Being super-alert, watchful, or on guard? Required
Feeling jumpy or easily startled? Required
In the past month have the above problems affected your relationships or social life? Required
Affected your work or ability to work? Required
Affected any other important part of your life such as parenting, or school or college work, or other important activities? Required

Below are problems that people who have had stressful or traumatic events sometimes experience. The questions refer to ways you TYPICALLY feel, ways you TYPICALLY think about yourself and ways you TYPICALLY relate to others. Answer the following thinking about how true each statement is of you.

When I am upset, it takes me a long time to calm down. Required
I feel numb or emotionally shut down. Required
I feel like a failure. Required
I feel worthless. Required
I feel distant or cut off from people. Required
I find it hard to stay emotionally close to people. Required
In the past month, have the above problems in emotions, in beliefs about yourself and in relationships created concern or distress about your relationships or social life? Required
In the past month, have the above problems affected your work or ability to work? Required
In the past month, have the above problems affected any other important parts of your life such as parenting, or school or college work, or other important activities? Required
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