PDS

Part 1						
Many People have lived through or witnessed a very stressful and traumatic event at some point in their lives.  Below is a list of traumatic events. Put a checkmark in the box next to ALL of the events that have happened to you or that you have witnessed.  

(1)		Serious accident, fire, or explosion (for example, an industrial, farm, car, plane, or boating accident)	
(2)		Natural disaster (for example, tornado, hurricane, flood, or major earthquake)	
(3)		Non-sexual assault by a family member or someone you know (for example, being mugged, physically attacked, shot, stabbed, or held at gunpoint)	
(4)		Non-sexual assault by a stranger (for example, being mugged, physically attacked, shot, stabbed, or held at gunpoint)	
(5)		Sexual assault by a family member or someone you know (for example, rape or attempted rape)	
(6)		Sexual assault by a stranger  (for example, rape or attempted rape)	
(7)		Military combat or war zone	
(8)		Sexual contact when you were younger than 18 with someone who was 5 or more years older than you (for example, contact with genitals, breasts)	
(9)		Imprisonment (for example, prison inmate, prisoner of war, hostage)	
(10)		Torture	
(11)		Life-threatening illness	
(12)		Other traumatic event	
(13)	If you marked item 12, specify the traumatic event below.

________________________________________

IF YOU MARKED ANY OF THE ITEMS ABOVE, CONTINUE.  IF NOT, STOP HERE.	

Part 2						
(14)  If you marked more than one traumatic event in Part 1, put a checkmark in the box below next to the event that bothers you the most.  If you marked only one traumatic event in Part 1, mark the same one below.

	Accident	
	Disaster	
	Non-sexual assault by family or someone you know	
	Non-sexual assault by a stranger	
	Sexual assault by family or someone you know	
	Sexual assault by a stranger	
	Combat	
	Sexual contact under 18 with someone 5 or more years older	
	Imprisonment	
	Torture	
	Life-threatening illness	
	Other	

In the lines below, briefly describe the traumatic event you marked above.
________________________________________________________________________________________________________________________________________________________________________________________
	
Below are several questions about the traumatic event you just described above.	
(15) How long ago did the traumatic event happen?
       (circle ONE)	
1	Less than 1 month	
2	1 to 3 months	
3	3 to 6 months	
4	6 months to 3 years	
5	3 to 5 years	
6	More than 5 years	

For the following questions, circle Y for Yes or N for No.

During this traumatic event:
(16)	Y	N	Were you physically injured?	
(17)	Y	N	Was someone else physically injured?	
(18)	Y	N	Did you think that your life was in danger?	
(19)	Y	N	Did you think that someone else’s life was in danger?	
(20)	Y	N	Did you feel helpless?	
(21)	Y	N	Did you feel terrified?	

Part 3						
Below is a list of problems that people sometimes have after experiencing a traumatic event.  Read each one carefully and circle the number (0-3) that best describes how often that problem has bothered you IN THE PAST MONTH.  Rate each problem with respect to the traumatic event you described in Item 14.

0	Not at all or only one time
1	Once a week or less/once in a while
2	2 to 4 times a week/half the time
3	5 or more times a week/almost always

(22)	0	1	2	3	Having upsetting thoughts or images about the traumatic event that came into your head when you didn’t want them to	
(23)	0	1	2	3	Having bad dreams or nightmares about the traumatic event	
(24)	0	1	2	3	Reliving the traumatic event, acting or feeling as if it was happening again	
(25)	0	1	2	3	Feeling emotionally upset when you were reminded of the traumatic event (for example, feeling scared, angry, sad, guilty, etc.)	
(26)	0	1	2	3	Experiencing physical reactions when you were reminded of the traumatic event (for example, breaking out in a sweat, heart beating fast)	
						
(27)	0	1	2	3	Trying not to think about, talk about, or have feelings about the traumatic event	
(28)	0	1	2	3	Trying to avoid activities, people, or places that remind you of the traumatic event	
(29)	0	1	2	3	Not being able to remember an important part of the traumatic event	
(30)	0	1	2	3	Having much less interest or participating much less often in important activities	
(31)	0	1	2	3	Feeling distant or cut off from people around you	
(32)	0	1	2	3	Feeling emotionally numb (for example, being unable to cry or unable to have loving feelings)	
(33)	0	1	2	3	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	
						
(34)	0	1	2	3	Having trouble falling or staying asleep	
(35)	0	1	2	3	Feeling irritable or having fits of anger	
(36)	0	1	2	3	Having trouble concentrating (for example, drifting in and out of conversation, losing track of a story on television, forgetting what you read)	
(37)	0	1	2	3	Being overly alert (for example, checking to see who is around you, being uncomfortable with your back to a door, etc.)	
(38)	0	1	2	3	Being jumpy or easily startled (for example, when someone walks up behind you)	

(39)	How long have you been experiencing the problems that you reported above? (circle ONE)
	
1	Less than 1 month
	
2	1 to 3 months
	
3	More than 3 months	
		
(40)	How long after the traumatic event did these    
         problems begin? (circle ONE)
	
1	Less than 6 months
	
2	6 or more months	

Part 4						
Indicate below if the problems you rate in Part 3 have interfered with any of the following areas of your life DURING THE PAST MONTH.  Circle Y for Yes and N for No.

(41)	Y	N	Work	
(42)	Y	N	Household chores and duties	
(43)	Y	N	Relationships with friends	
(44)	Y	N	Fun and leisure activities	
(45)	Y	N	Schoolwork	
(46)	Y	N	Relationships with your family	
(47)	Y	N	Sex life	
(48)	Y	N	General satisfaction with life	
(49)	Y	N	Overall level of functioning in all areas of your life