Atomic Shrink, Incorporated

​818-481-6581

PCL-5 | Dr. Patricia Masuda-Story
Confidential patient questionnaire

PCL-5

PTSD Checklist for DSM-5

Please answer every item according to how much each problem has bothered you during the past month. The form will calculate your score and prepare the completed responses for Dr. Story.

Patricia Masuda-Story, Psy.D., QME drstory@atomicshrink.com
Questionnaire progress0 of 20 answered

Patient Information

Complete the identifying information below before beginning the questionnaire.

Instructions

In the past month, how much were you bothered by each problem? Read each problem carefully and select one response. Answer every item before sending the form.
0Not at all
1A little bit
2Moderately
3Quite a bit
4Extremely
Total Score 0 / 80
After selecting “SEND COMPLETED FORM,” your email application will open with the score and responses addressed to Dr. Story. Select Send in the email application to complete delivery.