DSM 5 - Self-Rated

Client's Legal Full Name*

Preferred Name

Date of Birth*

Date

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.

Little Interest or pleasure in doing things?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Feeling down, depressed or hopeless?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Feeling more irritated, grouchy, or angry than usual?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Sleeping less than usual, but still have a lot of energy?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Starting lots more projects than usual or doing more risky things than usual?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Feeling nervous, anxious, frightened, worried or on edge?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Feeling panic or being frightened? *

	0	1	2	3	4	5

0 is None, 5 is Severe

Avoiding situations that make you anxious?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Unexplained aches and pains (e.g head, back, joints, abdomen, legs)*

	0	1	2	3	4	5

0 is None, 5 is Severe

Feeling that your illnesses are not being taken seriously enough?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Thoughts of actually hurting yourself?*

	0	1	2	3	4	5

0 is None, 5 is Best

Hearing things other people couldn't hear, such as voices even when no one was around?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Problems with sleep that affected your sleep quality over all? *

	0	1	2	3	4	5

0 is None, 5 is Severe

Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)*

	0	1	2	3	4	5

0 is None, 5 is Severe

Unpleasant thoughts, urges, or images that repeatedly enter your mind?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Feeling driven to perform certain behaviors or mental acts over and over again?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Feeling detached or distant from yourself, your body, your physical surroundings or your memories? *

	0	1	2	3	4	5

0 is None, 5 is Severe

Not knowing who you really are or what you want out of life?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Not feeling close to other people or enjoying your relationship with them?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Drinking at least 4 drinks of any kind of alcohol in a single day?*

	0	1	2	3	4	5

0 is None, 5 is Severe

Smoking any Cigarettes, a cigar, a pipe or using snuff or chewing tobacco? *

	0	1	2	3	4	5

0 is None, 5 is Severe

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, stimulants, sedatives or tranquilizers, or drugs like marijuana, cocaine or crack,club drugs, hallucinogens, heroin, inhalants or solvents, or methamphetamine? *

	0	1	2	3	4	5

0 is None, 5 is Severe

Date

Signature*