[form] PTSD Symptom SCALE Your Name please: [text,r_name,30] Email: [text,r_email,30] 1. Having upsetting thoughts or images about the traumatic event that came into your head when you didn’t want them to? [radio,ptsd1,0 Not At All,checked] Not At All [radio,ptsd1,1 Rarely] Rarely [radio,ptsd1,3 Sometimes] Sometimes [radio,ptsd1,5 Often] Often 2. Having bad dreams or nightmares about the traumatic event? [radio,ptsd2,0 Not At All,checked] Not At All [radio,ptsd2,1 Rarely] Rarely [radio,ptsd2,3 Sometimes] Sometimes [radio,ptsd2,5 Often] Often 2a. Having these bad dreams always centre on being killed? [radio,ptsd2a,0 Not At All,checked] Not At All [radio,ptsd2a,1 Rarely] Rarely [radio,ptsd2a,3 Sometimes] Sometimes [radio,ptsd2a,5 Often] Often 3. Reliving the traumatic event, acting or feeling as if it were happening again? [radio,ptsd3,0 Not At All,checked] Not At All [radio,ptsd3,1 Rarely] Rarely [radio,ptsd3,3 Sometimes] Sometimes [radio,ptsd3,5 Often] Often 3a. Reliving the traumatic event as if I am moving in a rewind motion? [radio,ptsd3a,0 Not At All,checked] Not At All [radio,ptsd3a,1 Rarely] Rarely [radio,ptsd3a,3 Sometimes] Sometimes [radio,ptsd3a,5 Often] Often 4. Feeling EMOTIONALLY upset when you were reminded of the traumatic event (for example feeling scared, angry, sad, guilty, etc.)? [radio,ptsd4,0 Not At All,checked] Not At All [radio,ptsd4,1 Rarely] Rarely [radio,ptsd4,3 Sometimes] Sometimes [radio,ptsd4,5 Often] Often 5. Experiencing PHYSICAL reactions (for example, break out in a sweat, heart beats fast) when you were reminded of the traumatic event? [radio,ptsd5,0 Not At All,checked] Not At All [radio,ptsd5,1 Rarely] Rarely [radio,ptsd5,3 Sometimes] Sometimes [radio,ptsd5,5 Often] Often 6. Trying not to think about, talk about, or have feelings about the traumatic event? [radio,ptsd6,0 Not At All,checked] Not At All [radio,ptsd6,1 Rarely] Rarely [radio,ptsd6,3 Sometimes] Sometimes [radio,ptsd6,5 Often] Often 6a. And when I try hard enough NOT to think about the traumatic event I feel dizzy? [radio,ptsd6a,0 Not At All,checked] Not At All [radio,ptsd6a,1 Rarely] Rarely [radio,ptsd6a,3 Sometimes] Sometimes [radio,ptsd6a,5 Often] Often 7. Trying to avoid activities, people, or places that remind you of the traumatic event? [radio,ptsd7,0 Not At All,checked] Not At All [radio,ptsd7,1 Rarely] Rarely [radio,ptsd7,3 Sometimes] Sometimes [radio,ptsd7,5 Often] Often 8. Not being able to remember an important part of the traumatic event? [radio,ptsd8,0 Not At All,checked] Not At All [radio,ptsd8,1 Rarely] Rarely [radio,ptsd8,3 Sometimes] Sometimes [radio,ptsd8,5 Often] Often 9. Having much less interest or participating much less often in important activities? [radio,ptsd9,0 Not At All,checked] Not At All [radio,ptsd9,1 Rarely] Rarely [radio,ptsd9,3 Sometimes] Sometimes [radio,ptsd9,5 Often] Often 9a. Having much MORE interest in activities that are unimportant? [radio,ptsd9a,0 Not At All,checked] Not At All [radio,ptsd9a,1 Rarely] Rarely [radio,ptsd9a,3 Sometimes] Sometimes [radio,ptsd9a,5 Often] Often 10. Feeling distant or cut off from people around you? [radio,ptsd10,0 Not At All,checked] Not At All [radio,ptsd10,1 Rarely] Rarely [radio,ptsd10,3 Sometimes] Sometimes [radio,ptsd10,5 Often] Often 11. Feeling emotionally numb (for example, being unable to cry or unable to have loving feelings) [radio,ptsd11,0 Not At All,checked] Not At All [radio,ptsd11,1 Rarely] Rarely [radio,ptsd11,3 Sometimes] Sometimes [radio,ptsd11,5 Often] Often 11a. Feeling emotionally transparent (for example, feeling like people are unable to see me) [radio,ptsd11a,0 Not At All,checked] Not At All [radio,ptsd11a,1 Rarely] Rarely [radio,ptsd11a,3 Sometimes] Sometimes [radio,ptsd11a,5 Often] Often 12. Feeling as if your future plans or hopes will not come true (for example, you will not have a career, marriage, children, or a long life)? [radio,ptsd12,0 Not At All,checked] Not At All [radio,ptsd12,1 Rarely] Rarely [radio,ptsd12,3 Sometimes] Sometimes [radio,ptsd12,5 Often] Often 13. Having trouble falling or staying asleep? [radio,ptsd13,0 Not At All,checked] Not At All [radio,ptsd13,1 Rarely] Rarely [radio,ptsd13,3 Sometimes] Sometimes [radio,ptsd13,5 Often] Often 14. Feeling irritable or having fits of anger? [radio,ptsd14,0 Not At All,checked] Not At All [radio,ptsd14,1 Rarely] Rarely [radio,ptsd14,3 Sometimes] Sometimes [radio,ptsd14,5 Often] Often 15. Having trouble concentrating (for example, drifting in and out of conversations, losing track of a story on television, forgetting what you read)? [radio,ptsd15,0 Not At All,checked] Not At All [radio,ptsd15,1 Rarely] Rarely [radio,ptsd15,3 Sometimes] Sometimes [radio,ptsd15,5 Often] Often 16. Being overly alert (for example, checking to see who is around you, being uncomfortable with your back to the door, etc.)? [radio,ptsd16,0 Not At All,checked] Not At All [radio,ptsd16,1 Rarely] Rarely [radio,ptsd16,3 Sometimes] Sometimes [radio,ptsd16,5 Often] Often 16a. Being overly aware of sensations or changes in my body? [radio,ptsd16a,0 Not At All,checked] Not At All [radio,ptsd16a,1 Rarely] Rarely [radio,ptsd16a,3 Sometimes] Sometimes [radio,ptsd16a,5 Often] Often 17. Being jumpy or easily startled (for example, when someone walks up behind you)? [radio,ptsd17,0 Not At All,checked] Not At All [radio,ptsd17,1 Rarely] Rarely [radio,ptsd17,3 Sometimes] Sometimes [radio,ptsd17,5 Often] Often 17a. Being acutely aware of smells, especially body odour? [radio,ptsd17a,0 Not At All,checked] Not At All [radio,ptsd17a,1 Rarely] Rarely [radio,ptsd17a,3 Sometimes] Sometimes [radio,ptsd17a,5 Often] Often ANY questions or comments? [textarea,questions or comments,3,70] [checkbox,send copy,checked] A COPY CHECK here to get a copy of your journal emailed to you. 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