(PTSD CHECKLIST)

Brief Checklist of Trauma Symptoms Check the symptoms below that you experience (that may or may not be related to a traumatic event) and make notes as needed: I experienced or witnessed a traumatic event during which I felt extreme fear, helplessness, or horror. The event happened on (day/month/year)_______________. What happened?________________________________________. I have symptoms of re-experiencing or re-living the traumatic event: Bad dreams or nightmares about the event or something similar Behaving or feeling as if the event were actually happening all over again (this is known as having flashbacks) Having a lot of emotional feelings when I am reminded of the event Having a lot of physical sensations when I am reminded of the event (e.g., my heart races or pounds, I sweat, find it hard to breathe, feel faint, feel like I'm going to lose control) I have symptoms of avoiding reminders of the traumatic event: Avoiding thoughts, conversations, or feelings that remind me about the event Avoiding people, places, or activities that remind me of the event Having difficulty remembering some important part of the event I have noticed that since the event happened: I have lost interest in, or just don't do, things that used to be important to me	I feel detached from people; I find it hard to trust people I feel emotionally "numb" and I find it hard to have loving feelings even toward those who are emotionally close to me	I have a hard time falling or staying asleep I am irritable and have problems with my anger I have a hard time concentrating I think I may not live very long and feel there's no point in planning for the future I am jumpy and get startled easily I am always "on guard" I experience these medical or emotional problems: Stomach problems Intestinal problems Gynecological problems Weight gain or loss Chronic pain (e.g., in my back, neck, pelvic area (in women)) Problems getting to sleep Problems staying asleep Headaches Skin rashes and other skin problems Irritability, a quick temper, and other anger problems Nightmares Depression Lack of energy, chronic fatigue Alcoholism and other substance use problems General anxiety Anxiety (panic) attacks Other symptoms such as: ______________________________ Other questions that you may want to ask your doctor or counselor: "What do people have to do to recover from PTSD?" "Why do I have PTSD and other people don't?" "Does having PTSD mean that I'm crazy or mentally ill?" "What will happen if I go for treatment?" "How long will treatment last?" "What will be the likely effects of treatment?" "What should I tell my spouse/partner/other family members about PTSD?" If medication treatment is discussed, you may want to ask some of these questions: "How is this medication supposed to help me?" "How will it affect my symptoms?" "How long will I have to take it?" "Can I stop it if I don't like it?" "How will we know if it is working?" "What will happen if it doesn't work?" "What are the side effects of the medication?" "How will it affect the other medications that I'm taking?" "Why do I need to go for counseling if I'm receiving medication treatment?" "How will medication treatment fit in with my PTSD counseling?" "How will medication affect my substance abuse recovery?" Again, if you think you have PTSD, or even just some of the symptoms, it is important for you to let your primary care physician know. This information is invaluable for planning your medical treatment. It can also help your doctor provide you with appropriate referrals for other services (e.g., to a psychologist, a social worker, child abuse protective services, lab tests, etc.). Retrieved from http://www.acc.gc.ca/clients/sub.cfm?source=mhealth/factsheets/discussing