INSTRUCTIONS TO PATIENT: Below is a list of problems and complaints that veterans sometimes have in response to stressful military experiences. Please read each one carefully, put an X in the box to indicate how much you have been bothered by that problem in the past month.

1.    Repeated, disturbing memories, thoughts, or images of a stressful military experience?

1. Not at all  2. A little bit  3. Moderately  4. Quite a bit  5. Extremely

2.    Repeated, disturbing dreams of a stressful military experience?

1. Not at all  2. A little bit  3. Moderately  4. Quite a bit  5. Extremely

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

1. Not at all  2. A little bit  3. Moderately  4. Quite a bit  5. Extremely

4.    Feeling very upset when something reminded you of a stressful military experience?

1. Not at all  2. A little bit  3. Moderately  4. Quite a bit  5. Extremely

5.    Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of a stressful military experience?

1. Not at all  2. A little bit  3. Moderately  4. Quite a bit  5. Extremely

6.    Avoiding thinking about or talking about a stressful military experience or avoiding having feelings related to it?

1. Not at all  2. A little bit  3. Moderately  4. Quite a bit  5. Extremely

1. Not at all  2. A little bit  3. Moderately  4. Quite a bit  5. Extremely

1. Not at all  2. A little bit  3. Moderately  4. Quite a bit  5. Extremely

1. Not at all  2. A little bit  3. Moderately  4. Quite a bit  5. Extremely

1. Not at all  2. A little bit  3. Moderately  4. Quite a bit  5. Extremely

1. Not at all  2. A little bit  3. Moderately  4. Quite a bit  5. Extremely

1. Not at all  2. A little bit  3. Moderately  4. Quite a bit  5. Extremely

1. Not at all  2. A little bit  3. Moderately  4. Quite a bit  5. Extremely

1. Not at all  2. A little bit  3. Moderately  4. Quite a bit  5. Extremely

1. Not at all  2. A little bit  3. Moderately  4. Quite a bit  5. Extremely

1. Not at all  2. A little bit  3. Moderately  4. Quite a bit  5. Extremely

Weathers, Litz, Huska, & Keane; National Center for PTSD - Behavioral Science Division. This is a government document in the public domain.

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