1 – Not at all
2 – Once or twice
3 – Almost every day
4 – About once a day
5 – More than once a day
¹
1
2
3
4
5
1
Things around me seemed strange or unreal.
2
I had moments when I lost control and acted like I was back in an upsetting time in my past.
3
I heard something that I know really wasn't there.
4
I felt like I was in a movie – like nothing that was happening was real.
5
I saw something that seemed real, but was not.
6
I suddenly realized that I hadn't been paying attention to what was going on around me.
7
I reacted to people or situations as if I were back in an upsetting time in my past.
8
I got so focused on something going on in my mind that I lost track of what was happening around me.
The presented answer sheet is not an original form and is not intended for printing or use as a handout.
The answer numbers are used only to label response columns. They are NOT scores and should not be used for calculating results.