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Practice name: ______________________________
PTSD Checklist (PCL-5) Screening
Your information
Patient Name *
Date of Screening
____ / ____ / ________
Brief Trauma Description
Repeated, disturbing memories
Repeated, disturbing dreams
Suddenly feeling as if the event were happening again
Avoiding memories, thoughts, or feelings
Additional details
Avoiding external reminders
Negative beliefs about yourself or the world
Loss of interest in activities
Feeling irritable or angry
Difficulty concentrating
PCL-5 Total Score
Provisional PTSD Interpretation
PTSD Checklist (PCL-5) Screening template from formisoft.com. formisoft.com/intake-templates/ptsd-pcl5-screening