MTP - Mefloquine, TBI, PTSD Symptom Scale - 20 items
(to be completed by a subject under supervision of a trained clinician)

    DATE:           TIME (24hr):      Patient Code:  

INSTRUCTIONS: Below is a list of problems and complaints that people sometimes have in response to toxic exposures, traumatic brain injury, and stressful experiences. Please read each one carefully, then click the circle to indicate how much you have been bothered by that problem in the past month, relative to how you were before the exposure.

  In the past month, how much were you bothered by:

at all

A little bit


a bit


  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 = 80

0    -  19      normal
20  -  39      mild
40  -  59      moderate
60  -  69      severe
70  -  80      extreme

Scale for toxic exposures, TBI, PTSD (5/18/2018)
First draft by Commander William Manofsky

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