Self-Rated Cross-Cutting Symptom Measure
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First & Last Name *
Age *
Sex
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Date:
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YYYY
If this questionnaire is completed by an informant, what is your relationship with the individual?
Instructions:
The questions below ask about the things that might have bothered you.  For each question, choose the number that best describes how much (or how often) you have been bothered by each problem during the past two weeks.
I.     During the past two (2) weeks, how much (or how often) have you been bothered by the following problems?
NONE None at all=0
SLIGHT Rare, less than a day or two=1
MILD Several Days=2
MODERATE More than half the days=3
SEVERE Nearly every day=4
1) Little interest or pleasure in doing things?
2) Feeling down, depressed, or hopeless?
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II.     During the past two (2) weeks, how much (or how often) have you been bothered by the following problems?
NONE None at all=0
SLIGHT Rare, less than a day or two=1
MILD Several Days=2
MODERATE More than half the days=3
SEVERE Nearly every day=4
3) Feeling more irritated, grouchy, or angry than usual?
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III.     During the past two (2) weeks, how much (or how often) have you been bothered by the following problems?
NONE None at all=0
SLIGHT Rare, less than a day or two=1
MILD Several Days=2
MODERATE More than half the days=3
SEVERE Nearly every day=4
4) Sleeping less than usual, but still have a lot of energy?
5) Starting lots more projects than usual or doing more risky things than usual?
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IV.     During the past two (2) weeks, how much (or how often) have you been bothered by the following problems?
NONE None at all=0
SLIGHT Rare, less than a day or two=1
MILD Several Days=2
MODERATE More than half the days=3
SEVERE Nearly every day=4
6) Feeling nervous, anxious, frightened, worried, or on edge?
7) Feeling panic or being frightened?
8) Avoiding situations that make you anxious?
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V.     During the past two (2) weeks, how much (or how often) have you been bothered by the following problems?
NONE None at all=0
SLIGHT Rare, less than a day or two=1
MILD Several Days=2
MODERATE More than half the days=3
SEVERE Nearly every day=4
9) Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)?
10) Feeling that your illnesses are not being taken seriously enough?
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VI.     During the past two (2) weeks, how much (or how often) have you been bothered by the following problems?
NONE None at all=0
SLIGHT Rare, less than a day or two=1
MILD Several Days=2
MODERATE More than half the days=3
SEVERE Nearly every day=4
11) Thoughts of actually hurting yourself?
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VII.     During the past two (2) weeks, how much (or how often) have you been bothered by the following problems?
NONE None at all=0
SLIGHT Rare, less than a day or two=1
MILD Several Days=2
MODERATE More than half the days=3
SEVERE Nearly every day=4
12) Hearing things that other people couldn't hear, such as voices even when no one was around?
13) Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?
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VIII.     During the past two (2) weeks, how much (or how often) have you been bothered by the following problems?
NONE None at all=0
SLIGHT Rare, less than a day or two=1
MILD Several Days=2
MODERATE More than half the days=3
SEVERE Nearly every day=4
14) Problems with sleep that affected your sleep quality overall?
Clear selection
IX.     During the past two (2) weeks, how much (or how often) have you been bothered by the following problems?
NONE None at all=0
SLIGHT Rare, less than a day or two=1
MILD Several Days=2
MODERATE More than half the days=3
SEVERE Nearly every day=4
15) Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)?
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X.     During the past two (2) weeks, how much (or how often) have you been bothered by the following problems?
NONE None at all=0
SLIGHT Rare, less than a day or two=1
MILD Several Days=2
MODERATE More than half the days=3
SEVERE Nearly every day=4
16) Unpleasant thoughts, urges, or images that repeatedly enter your mind?
17) Feeling driven to perform certain behaviors or mental acts over and over again?
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XI.     During the past two (2) weeks, how much (or how often) have you been bothered by the following problems?
NONE None at all=0
SLIGHT Rare, less than a day or two=1
MILD Several Days=2
MODERATE More than half the days=3
SEVERE Nearly every day=4
18) Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?
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XII.     During the past two (2) weeks, how much (or how often) have you been bothered by the following problems?
NONE None at all=0
SLIGHT Rare, less than a day or two=1
MILD Several Days=2
MODERATE More than half the days=3
SEVERE Nearly every day=4
19) Not knowing who you really are or what you want out of life?
20) Not feeling close to other people or enjoying your relationships with them?
Row 3
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XIII.     During the past two (2) weeks, how much (or how often) have you been bothered by the following problems?
NONE None at all=0
SLIGHT Rare, less than a day or two=1
MILD Several Days=2
MODERATE More than half the days=3
SEVERE Nearly every day=4
21) Drinking at least 4 drinks of any kind of alcohol in a single day?
22) Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco?
23) Using any of the following medicines ON YOUR OWN, that is without a doctor's prescription, in greater amounts or longer than prescribed [e.g., painkillers (like Vicodin), stimulants (like Ritalin or Adderall), Sedatives or tranquilizers (like sleeping pills or Valium), or drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)?
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