PCL-5
Created by
Michael Lee
Specialty
Psychiatrist
Last edited
10/20/2026
Uses
0 times
Tags
About this template
This template structures the assessment of PTSD-related symptoms using the PCL-5 response scale. It covers trauma-related memories, avoidance, mood and cognition changes, arousal, reactivity, and sleep, while recording only explicitly provided or selected information.
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Your Worst Event
High-speed MVA on 14/11/2023 resulting in brief LOC, rib fractures, and prolonged vehicle extrication.
In the past month, how much were you bothered by
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Repeated, disturbing, and unwanted memories of the stressful experience? [x] 3 - Quite a bit
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Repeated, disturbing dreams of the stressful experience? [x] 2 - Moderately
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Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were back there reliving it)? [x] 1 - A little bit
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Feeling very upset when something reminded you of the stressful experience? [x] 3 - Quite a bit
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Having strong physical reactions when something reminded you of the stressful experience (e.g., heart pounding, trouble breathing, sweating)? [x] 3 - Quite a bit
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Avoiding memories, thoughts, or feelings related to the stressful experience? [x] 3 - Quite a bit
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Avoiding external reminders of the stressful experience (e.g., people, places, conversations, activities, objects, or situations)? [x] 4 - Extremely
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Trouble remembering important parts of the stressful experience? [x] 1 - A little bit
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Having strong negative beliefs about yourself, other people, or the world (e.g., "I am bad," "No one can be trusted," "The world is completely dangerous")? [x] 2 - Moderately
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Blaming yourself or someone else for the stressful experience or its aftermath? [x] 3 - Quite a bit
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Having strong negative feelings such as fear, horror, anger, guilt, or shame? [x] 3 - Quite a bit
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Loss of interest in activities that you used to enjoy? [x] 2 - Moderately
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Feeling distant or cut off from other people? [x] 2 - Moderately
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Trouble experiencing positive feelings (e.g., unable to feel happiness or have loving feelings)? [x] 1 - A little bit
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Irritable behavior, angry outbursts, or acting aggressively? [x] 2 - Moderately
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Taking too many risks or doing things that could cause you harm? [x] 0 - Not at all
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Being “superalert” or watchful or on guard? [x] 4 - Extremely
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Feeling jumpy or easily startled? [x] 3 - Quite a bit
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Having difficulty concentrating? [x] 2 - Moderately
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Trouble falling or staying asleep? [x] 3 - Quite a bit
How to use this template
This template can be used to assist with various tasks in the medical field. You can use it to generate notes, manage patient information, or assist with diagnosis and the Assessment and Plan. To use this template, simply click the “Use Template” button above. If you have any questions or need assistance, feel free to reach out to the support team or refer to the description and example output provided above.