DSM 5 - Self Rated Symptom Measure

Client's Legal Full Name*

Age

Gender

Date*

Date

Instructions: The questions below ask about things that might have bothered you. For each questions, select the outcome that best describes how much (or how often) you have been bothered by each problem during the past two (2) weeks.

Been bothered by stomach aches, headaches or other aches and pains?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Worried about your health or about getting sick?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Been bothreed by not being able to fall asleep, stay asleep or by waking up too early?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Been bothered by not being able to pay attention when you were in class or doing homework or reading a book or playing a game?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Had less fun doing things than you used to?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Felt sad or depressed for several hours?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Felt more irritated or easily annoyed than usual?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Felt angry or lost their temper?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Started lots more projects than usual, or did more risky things?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Slept less than usual for them, but still had lots of energy?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Felt nervous, anxious, or scared?*

	0	1	2	3	4	5

0 is None, 5 is Best

Not been able to stop worrying?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Not been able to do things you wanted to do or should have done because they made you feel nervous?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Heard voices - when there was no one there - speaking about you or telling you what to do or saying bad things to you?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Had a vision when you were completely awake - that is, saw something or someone that no one else could see?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Had thoughts that kept coming into your mind that you would do something bad or that something bad would happen to you or someone else?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Felt the need to check on certain things over and over again, like whether a door is locked or whether the stove was turned off?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Worried a lot about things you touched being dirty or having germs or being poisoned?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Felt you had to do things in a certain way, like counting or saying special things out loud, in order to keep something bad from happening?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Had an alcoholic beverage (beer,wine,liquor, etc)*

	0	1	2	3	4	5

0 is None, 5 is Severe

Smoked a cigarette, a cigar, a pipe or used snuff or chewing tobacco?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Used drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Used any medicine without a doctor's prescription( eg, painkillers (like Vicodin), stimulants (like Ritalin), sedatives or tranquilizers (like sleeping pills, Valium or steroids) *

	0	1	2	3	4	5

0 is None, 5 is Severe

In the past two (2) weeks, have you thought about wanting to kill yourself or committing suicide*

YesNoUnsure

Have you EVER tried to kill yourself?*

YesNoUnsure

Signature*

Clear

DSM 5 - Self Rated Symptom Measure - age 11-17