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Distress and lifestyle questionnaires Page 1 of 5

There is no need to write your name on the answer forms. There are also no good and right answers. Completing the
questionnaires is consenting that we use these data anonymously for research purposes. If you do have questions,
please contact the research assistant which is available for you.

Kessler-6

The following questions ask about how you have been feeling during the past 30 days. For each question, please circle the
number that best describes how often you had this feeling.

During the past 30 days, about how often did you feel All of Most of Some of A little of None of
… the time the time the time the time the time
1. …nervous? 1 2 3 4 5
2. …hopeless? 1 2 3 4 5
3. …restless or fidgety? 1 2 3 4 5
4. …so depressed that nothing could cheer you 1 2 3 4 5
up?
5. …that everything was an effort? 1 2 3 4 5
6. …worthless? 1 2 3 4 5

PCL-5

Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem
carefully and then circle one of the numbers to the right to indicate how much you have been bothered by that problem in the
past 30 days.

In the past month, how much were you bothered by: Not at A little Moderatel Quite a Extremely
all bit y bit
NOTE THE POSSIBLE ANSWERS ARE DIFFERENT THAN FOR THE
KESSLER-6

1 Repeated, disturbing, and unwanted memories of the 0 1 2 3 4

stressful experience?
2 Repeated, disturbing dreams of the stressful experience? 0 1 2 3 4
3 Suddenly feeling or acting as if the stressful experience 0 1 2 3 4
were actually happening again (as if you were actually
back there reliving it)?
4 Feeling very upset when something reminded you of the 0 1 2 3 4
stressful experience?
5 Having strong physical reactions when something 0 1 2 3 4
reminded you of the stressful experience (for example,
heart pounding, trouble breathing, sweating)?
6 Avoiding memories, thoughts, or feelings related to the 0 1 2 3 4
stressful experience?
7 Avoiding external reminders of the stressful experience 0 1 2 3 4
(for example, people, places, conversations, activities,
objects, or situations)?
8 Trouble remembering important parts of the stressful 0 1 2 3 4
experience?
9 Having strong negative beliefs about yourself, other 0 1 2 3 4
people, or the world (for example, having thoughts such
as: I am bad, there is something seriously wrong with
me, no one can be trusted, the world is completely
dangerous)?
10 Blaming yourself or someone else for the stressful 0 1 2 3 4
experience or what happened after it?
11 Having strong negative feelings such as fear, horror, 0 1 2 3 4
anger, guilt, or shame?
12 Loss of interest in activities that you used to enjoy? 0 1 2 3 4
13 Feeling distant or cut off from other people? 0 1 2 3 4
14 Trouble experiencing positive feelings (for example, 0 1 2 3 4
being unable to feel happiness or have loving feelings for
people close to you)?
15 Irritable behavior, angry outbursts, or acting 0 1 2 3 4
aggressively?
16 Taking too many risks or doing things that could cause 0 1 2 3 4
you harm?
17 Being “superalert” or watchful or on guard? 0 1 2 3 4
18 Feeling jumpy or easily startled? 0 1 2 3 4
19 Having difficulty concentrating? 0 1 2 3 4
20 Trouble falling or staying asleep? 0 1 2 3 4
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Distress and lifestyle questionnaires Page 2 of 5

Professional Quality of Life Scale – 5 (PQLS-5)

When you help people you have direct contact with their lives. As you may have found, your compassion for those you help can
affect you in positive and negative ways. Below are some questions about your experiences, both positive and negative, as a
health care professional. Consider each of the following questions about you and your current work situation. Select the number
that honestly reflects how frequently you experienced these things in the last 30 days.

Never Rarely Some- Often Very

times often
1 I am happy. 1 2 3 4 5
2 I am preoccupied with more than one person I help. 1 2 3 4 5
3 I get satisfaction from being able to help people. 1 2 3 4 5
4 I feel connected to others. 1 2 3 4 5
5 I jump or am startled by unexpected sounds. 1 2 3 4 5
6 I feel invigorated after working with those I help. 1 2 3 4 5
7 I find it difficult to separate my personal life from my life as a health care 1 2 3 4 5
professional.
8 I am not as productive at work because I am losing sleep over traumatic 1 2 3 4 5
experiences of a person I help.
9 I think that I might have been affected by the traumatic stress of those I 1 2 3 4 5
help.
10 I feel trapped by my job as a health care professional. 1 2 3 4 5
11 Because of my job, I have felt "on edge" about various things. 1 2 3 4 5
12 I like my work as a health care professional. 1 2 3 4 5
13 I feel depressed because of the traumatic experiences of the people I 1 2 3 4 5
help.
14 I feel as though I am experiencing the trauma of someone I have 1 2 3 4 5
helped.
15 I have beliefs that sustain me. 1 2 3 4 5
16 I am pleased with how I am able to keep up with health care techniques 1 2 3 4 5
and protocols.
17 I am the person I always wanted to be. 1 2 3 4 5
18 My work makes me feel satisfied. 1 2 3 4 5
19 I feel worn out because of my work as a health cate professional. 1 2 3 4 5
20 I have happy thoughts and feelings about those I help and how I could 1 2 3 4 5
help them.
21 I feel overwhelmed because my work load seems endless. 1 2 3 4 5
22 I believe I can make a difference through my work. 1 2 3 4 5
23 I avoid certain activities or situations because they remind me of 1 2 3 4 5
frightening experiences of the people I help.
24 I am proud of what I can do to help. 1 2 3 4 5
25 As a result of my helping I have intrusive, frightening thoughts. 1 2 3 4 5
26 I feel "bogged down" by the system. 1 2 3 4 5
27 I have thoughts that I am a "success" as a health care professional. 1 2 3 4 5
28 I can't recall important parts of my work with trauma victims. 1 2 3 4 5
29 I am a very caring person. 1 2 3 4 5
30 I am happy that I chose to do this work. 1 2 3 4 5
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Physical Activity Vital Sign

1. On average how many days per week do you engage in moderate to vigorous physical activity like a brisk walk?” This
means that due to being active your heart rate increased and you breathed more deeply and faster than normal, with
some maybe even experiencing sweating.

….. days

2. On those days, how many minutes do you engage on average in physical activity at this level?

….. minutes

Simple Physical Activity Questionnaire

Introduction: Think about what you have been doing over the past seven days, including time spent in bed, sitting or lying down,
walking, exercise, sport and other activities.

1. What is the average number of hours per day you spend in bed? Answer: ______ am/pm

2. That leaves approximately ___ (24 minus the hours you spent in bed above) hours a day out of bed. Out of those ___
hours, how long did you spend sitting or lying down, such as when you are eating, reading, watching TV or using
electronic devices? Prompt: e.g. sitting at work, transport, leisure-time or at home.

Answer: ______ Hours ______ minutes /day

3. That leaves approximately ___ hours a day for other activities (24 hours minus hours in bed minus hours sedentary).
Which days in the past seven days did you walk for exercise or recreation or to get to or from places? How many
minutes did you usually spend walking on those days?

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

4. Now think about any activity that you do for exercise and sport, such as jogging, running, swimming, bike riding, going
to the gym, yoga, ______[e.g. 1] or ______[e.g. 2]. Which days in the past week did you do any of these, or similar
activities and what activities did you do and how much time did you spend on each activity on each day?

Activity Minutes
Example Soccer 15
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

5. Now think about any other physical activities that you did as part of your work, or activities you did while at home such
as gardening or household chores. How many minutes did you spend on these activities on most days? Prompt: this
does not include walking, sport or exercise

Answer: ___________Minutes/day

AUDIT-C

How often did you have a drink containing alcohol in the past year?
Never 0
Monthly or less 1
Two to four times a month 2
Two to three times a week 3
Four or more times a week 4

How many drinks did you have on a typical day when you were drinking in the past year?
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None, I don’t drink 0

1 or 2 0
3 or 4 1
5 or 6 2
7 to 9 3
10 or more 4

How often did you have six or more drinks on one occasion in the past year?
Never 0
Less than monthly 1
Monthly 2
Weekly 3
Daily 4

Smoking

Do you smoke? Yes or no? ….. If yes: how many cigarettes per day on average: ….

Pittsburgh Sleep Quality Index

The following questions relate to your usual sleep habits during the past month only. Your answers should indicate the most
accurate reply for the majority of days and nights in the past month. Please answer all questions.

1. During the past month, what time have you usually gone to bed at night? ___________________

2. During the past month, how long (in minutes) has it usually taken you to fall asleep each night? ___________________

3. During the past month, what time have you usually gotten up in the morning? ___________________

4. During the past month, how many hours of actual sleep did you get at night? (This may be different than the number of hours
you spent in bed.) ___________________

During the past month, how often have you had Not during Less than Once or 3 or more
trouble sleeping because you… the past once per twice per times per
month week week week
5 Cannot get to sleep within 30 minutes 0 1 2 3
6 Wake up in the middle of the night or early morning 0 1 2 3
7 Have to get up to use the bathroom 0 1 2 3
8 Cannot breathe comfortably 0 1 2 3
9 Cough or snore loudly 0 1 2 3
10 Feel too cold 0 1 2 3
11 Feel too hot 0 1 2 3
12 Have bad dreams 0 1 2 3
13 Have pain 0 1 2 3
14 Other reason 0 1 2 3
15 During the past month, how often have you taken 0 1 2 3
medicine to help you sleep (prescribed or “over the
counter”)?
16 During the past month, how often have you had trouble
staying awake while driving, eating meals, or engaging 0 1 2 3
in social activity?
No Only a Somewhat A very big
problem at very slight of a problem
all problem problem
17 During the past month, how much of a problem has it
been for you to keep up enough enthusiasm to get 0 1 2 3
things done?
Very good Fairly Fairly bad Very bad
good
18 During the past month, how would you rate your sleep
quality overall? 0 1 2 3
If we would ask your bedroom partner, if you have Not during Yes, less Yes, once Yes, three
one, about the past month, would he/she confirm the past than once or twice per or more
the following of your sleep behavior? month a week week times per
week
19 Loud snoring 0 1 2 3
20 Long pauses between breaths while asleep 0 1 2 3
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21 Legs twitching or jerking while you sleep 0 1 2 3

22 Episodes of disorientation or confusion 0 1 2 3
23 Other restlessness while you sleep 0 1 2 3