ReST Hub

Instructions: Please identify the experience that troubles you most and answer the questions in relation to this experience.

Brief description of the experience

When did the experience occur?

Less than 6 months ago

6 to 12 months ago

1 to 5 years ago

5 to 10 years ago

10 to 20 years ago

More than 20 years ago

Below are a number of problems that people sometimes report in response to traumatic or stressful life events. Please read each item carefully, then select 0, 1, 2, 3 or 4 to indicate how much you have been bothered by that problem in the past month.

0 Not at all

1 A little bit

2 Moderately

3 Quite a bit

4 Extremely

	0	1	2	3	4
(P1) Having upsetting dreams that replay part of the experience or are clearly related to the experience?	0 Not at all	1 A little bit	2 Moderately	3 Quite a bit	4 Extremely
(P2) Having powerful images or memories that sometimes come into your mind in which you feel the experience is happening again in the here and now?	0 Not at all	1 A little bit	2 Moderately	3 Quite a bit	4 Extremely
(P3) Avoiding internal reminders of the experience (for example, thoughts, feelings, or physical sensations)?	0 Not at all	1 A little bit	2 Moderately	3 Quite a bit	4 Extremely
(P4) Avoiding external reminders of the experience (for example, people, places, conversations, objects, activities, or situations)?	0 Not at all	1 A little bit	2 Moderately	3 Quite a bit	4 Extremely
(P5) Being “super-alert”, watchful, or on guard?	0 Not at all	1 A little bit	2 Moderately	3 Quite a bit	4 Extremely
(P6) Feeling jumpy or easily startled?	0 Not at all	1 A little bit	2 Moderately	3 Quite a bit	4 Extremely

In the past month have the above problems:

0 Not at all

1 A little bit

2 Moderately

3 Quite a bit

4 Extremely

	0	1	2	3	4
(P7) Affected your relationships or social life?	0 Not at all	1 A little bit	2 Moderately	3 Quite a bit	4 Extremely
(P8) Affected your work or ability to work?	0 Not at all	1 A little bit	2 Moderately	3 Quite a bit	4 Extremely
(P9) Affected any other important part of your life such as parenting, or school or college work, or other important activities?	0 Not at all	1 A little bit	2 Moderately	3 Quite a bit	4 Extremely

Below are problems that people who have had stressful or traumatic events sometimes experience. The questions refer to ways you typically feel, ways you typically think about yourself and ways you typically relate to others.

Answer the following thinking about how true each statement is of you.

0 Not at all

1 A little bit

2 Moderately

3 Quite a bit

4 Extremely

	0	1	2	3	4
(C1) When I am upset, it takes me a long time to calm down.	0 Not at all	1 A little bit	2 Moderately	3 Quite a bit	4 Extremely
(C2) I feel numb or emotionally shut down.	0 Not at all	1 A little bit	2 Moderately	3 Quite a bit	4 Extremely
(C3) I feel like a failure.	0 Not at all	1 A little bit	2 Moderately	3 Quite a bit	4 Extremely
(C4) I feel worthless.	0 Not at all	1 A little bit	2 Moderately	3 Quite a bit	4 Extremely
(C5) I feel distant or cut off from people.	0 Not at all	1 A little bit	2 Moderately	3 Quite a bit	4 Extremely
(C6) I find it hard to stay emotionally close to people.	0 Not at all	1 A little bit	2 Moderately	3 Quite a bit	4 Extremely

In the past month, have the above problems in emotions, in beliefs about yourself and in relationships:

0 Not at all

1 A little bit

2 Moderately

3 Quite a bit

4 Extremely

	0	1	2	3	4
(C7) Created concern or distress about your relationships or social life?	0 Not at all	1 A little bit	2 Moderately	3 Quite a bit	4 Extremely
(C8) Affected your work or ability to work?	0 Not at all	1 A little bit	2 Moderately	3 Quite a bit	4 Extremely
(C9) Affected any other important parts of your life such as parenting, or school or college work, or other important activities?	0 Not at all	1 A little bit	2 Moderately	3 Quite a bit	4 Extremely

Are you troubled by shocking or painful events that happened in the past?