Trauma Study

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CAPS-5 SUMMARY SHEET

Name: ___________________________ ID#: ________ Interviewer: ___________________________ Study: _____________ Date:

A. Exposure to actual or threatened death, serious injury, or sexual violence Criterion A met? 0 = NO 1= YES

B. Intrusion symptoms (need 1 for diagnosis) Past Week Symptom Sev Sx (Sev > 2 )? (1) B1 – Intrusive memories 0 = NO 1= YES (2) B2 – Distressing dreams 0 = NO 1= YES (3) B3 – Dissociative reactions 0 = NO 1= YES (4) B4 – Cued psychological distress 0 = NO 1= YES (5) B5 – Cued physiological reactions 0 = NO 1= YES

B subtotals B Sev = #B Sx =

C. Avoidance symptoms (need 1 for diagnosis) Past Week Symptom Sev Sx (Sev > 2 )? (6) C1 – Avoidance of memories, thoughts, feelings 0 = NO 1= YES (7) C2 – Avoidance of external reminders 0 = NO 1= YES

C subtotals C Sev = #C Sx =

D. Cognitions and mood symptoms (need 2 for diagnosis) Past Week Symptom Sev Sx (Sev > 2 )? (8) D1 – Inability to recall important aspect of event 0 = NO 1= YES (9) D2 – Exaggerated negative beliefs or expectations 0 = NO 1= YES (10) D3 – Distorted cognitions leading to blame 0 = NO 1= YES (11) D4 – Persistent negative emotional state 0 = NO 1= YES (12) D5 – Diminished interest or participation in activities 0 = NO 1= YES (13) D6 – Detachment or estrangement from others 0 = NO 1= YES (14) D7 – Persistent inability to experience positive emotions 0 = NO 1= YES

D subtotals D Sev = #D Sx =

E. Arousal and reactivity symptoms (need 2 for diagnosis) Past Week Symptom Sev Sx (Sev > 2 )? (15) E1 – Irritable behavior and angry outbursts 0 = NO 1= YES (16) E2 – Reckless or self-destructive behavior 0 = NO 1= YES (17) E3 – Hypervigilance 0 = NO 1= YES (18) E4 – Exaggerated startle response 0 = NO 1= YES (19) E5 – Problems with concentration 0 = NO 1= YES (20) E6 – Sleep disturbance 0 = NO 1= YES

E subtotals E Sev = #E Sx =

CAPS-5 Past Week (16 April 2018) National Center for PTSD

0 0

0 0

0 0

0 0

Page 2CAPS-5 Past Week (16 April 2018) 1 of 21

PTSD totals Past Week Totals Total Sev Total # Sx

Sum of subtotals (B+C+D+E)

F. Duration of disturbance Current (22) NOT APPLICABLE

G. Distress or impairment (need 1 for diagnosis) Past Week Criterion Sev Cx (Sev > 2 )? (23) Subjective distress 0 = NO 1= YES (24) Impairment in social functioning 0 = NO 1= YES (25) Impairment in occupational functioning 0 = NO 1= YES

G subtotals G Sev = #G Cx =

Global ratings Past Week (26) Global validity (27) Global severity (28) Global improvement

Dissociative symptoms (need 1 for subtype) Past Week Symptom Sev Sx (Sev > 2 )? (29) 1 – Depersonalization 0 = NO 1= YES (30) 2 – Derealization 0 = NO 1= YES

Dissociative subtotals Diss Sev = #Diss Sx =

National Center for PTSDNational Center for PTSD

0 0

0 0

0 0