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Name *
Part 1
Instructions: 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.
1. Natural disaster (for example, flood, hurricane, tornado, earthquake) *
2. Fire or explosion *
3. Transportation accident (for example, car accident, boat accident, train wreck, plane crash) *
4. Serious accident at work, home, or during recreational activity *
5. Exposure to toxic substance (for example, dangerous chemicals, radiation) *
6. Physical assault (for example, being attacked, hit, slapped, kicked, beaten up) *
7. Assault with a weapon (for example, being shot, stabbed, threatened with a knife, gun, bomb) *
8. Sexual assault (rape, attempted rape, made to perform any type of sexual act through force or threat of harm) *
9. Other unwanted or uncomfortable sexual experience *
10. Combat or exposure to a war-zone (in the military or as a civilian) *
11. Captivity (for example, being kidnapped, abducted, held hostage, prisoner of war) *
12. Life-threatening illness or injury *
13. Severe human suffering *
14. Sudden violent death (for example, homicide, suicide) *
15. Sudden accidental death *
16. Serious injury, harm, or death you caused to someone else *
17. Any other very stressful event or experience *
Part 2
A. If you checked anything for #17 in PART 1, briefly identify the event you were thinking of: B. If you have experienced more than one of the events in PART 1, think about the event you consider the worst event, which for this questionnaire means the event that currently bothers you the most. If you have experienced only one of the events in PART 1, use that one as the worst event. Please answer the following questions about the worst event (check all options that apply)
How did you experience it? *
Was someone's life in danger? *
Was someone seriously injured or killed? *
Did it involve sexual violence? *
If the event involved the death of a close family member or close friend, was it due to some kind of accident or violence, or was it due to natural causes? *
How many times altogether have you experienced a similar event as stressful or nearly as stressful as the worst event? *
Part 3
Below is a list of problems that people sometimes have in response to a very stressful experience. Keeping your worst event in mind, please read each problem carefully and then circle one of the numbers to the right to indicate how much you have been bothered by that problem in the past month.
1. Repeated, disturbing, and unwanted memories of the stressful experience? *
2. Repeated, disturbing dreams of the stressful experience? *
3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)? *
4. Feeling very upset when something reminded you of the stressful experience? *
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)? *
6. Avoiding memories, thoughts, or feelings related to the stressful experience? *
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)? *
8. Trouble remembering important parts of the stressful experience? *
9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)? *
10. Blaming yourself or someone else for the stressful experience or what happened after it? *
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame? *
12. Loss of interest in activities that you used to enjoy? *
13. Feeling distant or cut off from other people? *
14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)? *
15. Irritable behaviour, angry outbursts, or acting aggressively? *
16. Taking too many risks or doing things that could cause you harm? *
17. Being “superalert” or watchful or on guard? *
18. Feeling jumpy or easily startled? *
19. Having difficulty concentrating? *
20. Trouble falling or staying asleep? *
Thank you!
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