PTSD Checklist Stressor Specific Version (PCL-S)

The PTSD Checklist is a standard screening test that is used in order to help people who may have experienced a traumatic event. If you are a natural mother who has been separatede from your infant by adoption, please fill this questionnaire to help determine if you are experiencing symptoms of post-traumatic stress as a result.

There are two purposes for this form. The first purpose is to help you. As a recognized screening test for PTSD, you can fill in this form, press "submit," and print off the results page to take to your doctor if you feel you want to get tested by a professional for PTSD. A diagnosis of PTSD means that you will be able to obtain treatment for the symptoms of post-traumatic stress. This treatment may involve being referred to a psychologist or a psychiatrist who specializes in trauma therapy.

The second use for this form is that, if you choose, you may anonymously donate your result score to a project being conducted by Origins International, to develop recommendations for post-surrender ("post-adoption") support services for natural mothers.

INSTRUCTIONS: Below is a list of problems and complaints that people sometimes have in response to stressful life experiences. Please read each one carefully, then choose one of the answers on the right to indicate how much you have been bothered by that problem in the past month.

	Not at all	A little bit	Moderately	Quite a bit	Extremely
1. Repeated, disturbing memories, thoughts, or images of the stressful experience?	1	2	3	4	5
2. Repeated, disturbing dreams of the stressful experience?	1	2	3	4	5
3. Suddenly acting or feeling as if the stressful experience were happening again (as if you were reliving it)?	1	2	3	4	5
4. Feeling very upset when something reminded you of the stressful experience?	1	2	3	4	5
5. Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the stressful experience?	1	2	3	4	5
6. Avoiding thinking about or talking about the stressful experience or avoiding having feelings related to it?	1	2	3	4	5
7. Avoiding activities or situations because they reminded you of the stressful experience?	1	2	3	4	5
8. Trouble remembering important parts of the stressful experience?	1	2	3	4	5
9. Loss of interest in activities that you used to enjoy?	1	2	3	4	5
10. Feeling distant or cut off from other people?	1	2	3	4	5
11. Feeling emotionally numb or being unable to have loving feelings for those close to you?	1	2	3	4	5
12. Feeling as if your future will somehow be cut short?	1	2	3	4	5
13. Trouble falling or staying asleep?	1	2	3	4	5
14. Feeling irritable or having angry outbursts?	1	2	3	4	5
15. Having difficulty concentrating?	1	2	3	4	5
16. Being "super-alert" or watchful or on guard?	1	2	3	4	5
17. Feeling jumpy or easily startled?	1	2	3	4	5

PCL-S for DSM-IV (11/1/94), Copyright Weathers, Litz, Huska, & Keane, National Center for PTSD.