Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results

Sign UpLogin With Facebook
Sign UpLogin With Google

PTSD CheckList - Civilian Version (PCL-C)

Assess Your Mental Health with the PCL-C Template

Experiencing distress after a traumatic event can leave you feeling overwhelmed and uncertain. This PCL-C template helps you accurately assess your PTSD symptoms to understand your emotional health and seek support where needed. With this tool, you can easily track changes in your mental state, identify potential triggers, and prepare for conversations with mental health professionals while ensuring compliance with relevant guidelines. Start using the live template today to take a positive step forward in your mental well-being.

Full name (optional)
Age range (optional)
Under 18
18-24
25-34
35-44
45-54
55-64
65+
Prefer not to say
If you prefer to self-describe your gender, please specify (optional)
Email (optional)
Date
Gender identity (optional)
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
I understand this checklist is a screening tool and not a diagnosis.
Yes
No
Have you experienced or witnessed a traumatic event?
Yes
No
In the past month, how much were you bothered by: Repeated, disturbing memories, thoughts, or images of a stressful experience.
Not at all
A little bit
Moderately
Quite a bit
Extremely
In the past month, how much were you bothered by: Repeated, disturbing dreams of a stressful experience.
Not at all
A little bit
Moderately
Quite a bit
Extremely
In the past month, how much were you bothered by: Suddenly feeling or acting as if the stressful experience were happening again (reliving it).
Not at all
A little bit
Moderately
Quite a bit
Extremely
In the past month, how much were you bothered by: Feeling very upset when something reminded you of the stressful experience.
Not at all
A little bit
Moderately
Quite a bit
Extremely
In the past month, how much were you bothered by: Physical reactions (for example, heart pounding, trouble breathing, sweating) when reminded of the stressful experience.
Not at all
A little bit
Moderately
Quite a bit
Extremely
In the past month, how much were you bothered by: Avoiding thoughts, feelings, or conversations about the stressful experience.
Not at all
A little bit
Moderately
Quite a bit
Extremely
In the past month, how much were you bothered by: Avoiding activities or situations that remind you of the stressful experience.
Not at all
A little bit
Moderately
Quite a bit
Extremely
In the past month, how much were you bothered by: Trouble remembering important parts of the stressful experience.
Not at all
A little bit
Moderately
Quite a bit
Extremely
In the past month, how much were you bothered by: Loss of interest in activities you used to enjoy.
Not at all
A little bit
Moderately
Quite a bit
Extremely
In the past month, how much were you bothered by: Feeling distant or cut off from other people.
Not at all
A little bit
Moderately
Quite a bit
Extremely
In the past month, how much were you bothered by: Feeling emotionally numb or unable to have loving feelings for those close to you.
Not at all
A little bit
Moderately
Quite a bit
Extremely
In the past month, how much were you bothered by: Feeling as if your future will be cut short.
Not at all
A little bit
Moderately
Quite a bit
Extremely
In the past month, how much were you bothered by: Trouble falling asleep or staying asleep.
Not at all
A little bit
Moderately
Quite a bit
Extremely
In the past month, how much were you bothered by: Feeling irritable or having angry outbursts.
Not at all
A little bit
Moderately
Quite a bit
Extremely
In the past month, how much were you bothered by: Difficulty concentrating.
Not at all
A little bit
Moderately
Quite a bit
Extremely
In the past month, how much were you bothered by: Being superalert or watchful on guard.
Not at all
A little bit
Moderately
Quite a bit
Extremely
In the past month, how much were you bothered by: Feeling jumpy or easily startled.
Not at all
A little bit
Moderately
Quite a bit
Extremely
If there is anything else you would like to share, please add it here (optional).
{"name":"Full name (optional)", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Full name (optional), Age range (optional), If you prefer to self-describe your gender, please specify (optional)","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration featuring a PTSD checklist for civilians with a focus on mental health and support resources.

When to use this form

Use this template during intake, post-incident check-ins, or routine reviews to screen adults for trauma symptoms. It fits primary care, college counseling, employee assistance, and telehealth. After a car crash, assault, disaster, or medical emergency, it gives you a baseline and a score you can trend over time. For broader context, pair it with the DSM-5 Level 1 cross-cutting symptom measure assessment form and the Mental health survey form. When grief is central to the story, add the Grief assessment form to separate loss reactions from trauma signs. The results help you triage, shape goals, and document progress.

Must Ask PTSD CheckList Civilian Version (PCL-C) Questions

  1. Over the past month, how often have you had unwanted memories of a very stressful event?

    This gauges intrusion severity and gives you a clear baseline for tracking change. High frequency flags acute distress and helps you plan grounding and pacing.

  2. Over the past month, how often have you avoided thoughts, feelings, or places that remind you of the event?

    Avoidance maintains symptoms and can block care. Knowing what you avoid helps you set exposure tasks that feel safe and doable.

  3. Over the past month, how much have sleep problems, irritability, or trouble concentrating bothered you?

    These arousal symptoms affect safety, mood, and performance. If irritability is high, add the Anger management evaluation form to target triggers and coping.

  4. When you are reminded of the event, how strong are your physical reactions (for example, heart racing, sweating)?

    Body cues reveal conditioned responses you can map and treat. Rating intensity helps you identify triggers and prepare brief interventions.

  5. How much have these problems interfered with your work, school, or relationships in the past month?

    Impairment shows clinical need and supports referrals or accommodations. Use the Case conceptualisation form to turn this impact into concrete goals and a plan.

More Forms

Copy/Edit Form Send to Recipients Make a Form w/AI Form Builder Must Ask Questions
  • 100% Free - No Catches
  • Collect Responses Today
  • Tailor to your Look & Feel