Toxic Exposure, TBI, PTSD Symptom Scale
(to be completed with a trained clinician)

       ID:         DATE:           TIME (24hr): 

INSTRUCTIONS: Please rate your symptoms by checking the one number that best describes your symptom
at its worst in the past month, for each symptom you have had:

Regions affected by pain: None mild moderate severe extreme
0 1 2 3 4 5 6 7 8 9 10
1.   Having unusual changes in mood?
2.   Feeling down or depressed?
3.   Noticing unexpected or unusual behavior in yourself?
4.   Getting angry with little or no provocation
5.   Having feelings of anxiety?
6.   Changes in your personality?
7.   Doing things implusively, without thinking them through?
8.   Having difficulty concentrating?
9.   Having difficulty with your memory?
10. Noticing period of confusion; not knowing the date, where you are?
11. Being afraid of crowds or being around groups of people?
12. Being paranoid, thinking people are planning to harm you?
13. Having difficulty sleeping at night (or during the day)?
14. Having nightmares that are very vivid, "technicolor"?
15. Difficulty with vision, visual impairment?
16. Thoughts about doing bad things?
17. Intrusive thoughts about life and death?
18. Difficulty with light sensitivity?
19. Feelings of being dizzy?
20. Feeling of being nauseated or vomiting?


MTP21  maximum score = 200

0    -  19      normal
20  -  59      mild
60  -  99      moderate
100  -  149      severe
150  -  200      extreme

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Last update: 10/13/2015