Yes No

Have you experienced or witnessed a life-threatening event that caused intense fear, helplessness or horror?

Yes No

Repeated, distressing memories and/or dreams?

Yes No

Acting or feeling as if the event were happening again (flashbacks or a sense of reliving it)?

Yes No

Intense physical and/or emotional distress when you are exposed to things that remind you of the event?

Yes No

Avoiding thoughts, feelings, or conversations about it?

Yes No

Avoiding activities, places, or people who remind you of it?

Yes No

Blanking on important parts of it?

Yes No

Losing interest in significant activities of you life?

Yes No

Feeling detached from other people?

Yes No

Feeling your range of emotions is restricted?

Yes No

Sensing that your future has shrunk (for example, you don't expect to have a career, marriage, children, or a normal life span)?

Yes No

Problems sleeping?

Yes No

Irritability or outbursts of anger?

Yes No

Problems concentrating?

Yes No

Feeling "on guard"?

Yes No

An exaggerated startle response?

Yes No

Have you experienced changes in sleeping or eating habits?

Yes No

Sad or depressed?

Yes No

Disinterested in life?

Yes No

Worthless or guilty?

Yes No

Resulted in your failure to fulfill responsibilities with work, school, or family?

Yes No

Placed you in a dangerous situation, such as driving a car under the influence?

Yes No

Gotten you arrested?

Yes No

Continued despite causing problems for you and/or your loved ones?

Yes No

Does the child have a distinct and ongoing fear of social situations involving unfamiliar people?

Yes No

Does the child worry excessively about a number of events or activities?

Yes No

Does the child experience shortness of breath or a racing heart for no apparent reason?

Yes No

Does the child experience age-appropriate social relationships with family members and other familiar people?

Yes No

Does the child often appear anxious when interacting with her peers and avoid them?

Yes No

Does the child have a persistent and unreasonable fear of an object or situation, such as flying, heights, or animals?

Yes No

When the child encounters the feared object or situation, does he react by freezing, clinging, or having a tantrum?

Yes No

Does the child worry excessively about her competence and quality of performance?

Yes No

Does the child cry, have tantrums, or refuse to leave a family member or other familiar person when she must?

Yes No

Has the child experienced a decline in classroom performance, refused to go to school, or avoided age-appropriate social activities?

Yes No

Does the child spend too much time each day doing things over and over again (for example, hand washing, checking things, or counting)?

Yes No

Does the child have exaggerated fears of people or events (i.e., burglars, kidnappers, car accidents) that might be difficult, such as in a crowd or on an elevator?

Yes No

Does the child experience a high number of nightmares, headaches, or stomachaches?

Yes No

Does the child repetitively re-enact with toys scenes from a disturbing event?

Yes No

Does the child redo tasks because of excessive dissatisfaction with less-than-perfect performance?