CY-BOCS Intake

Date*

Date

Patient Name*

First NameLast Name

CY-BOCS Symptom Checklist

CY-BOCS Obsessions Checklist

Instructions: Generate a Target Symptoms List from the CY-BOCS Symptom Checklist by asking about specific obsessions and compulsions. Select all that apply. Distinguish between current and past symptoms and mark principal symptoms. These will form the basis of the Target Symptoms List (Items marked * may or may not be OCD Phenomena)

CONTAMINATION OBSESSIONS:

	Current	Past	Principle
Concern with dirt, germs, certain illnsses (e.g. AIDS)
Concerns or disgust with bodily waste or secretions (e.g. urine, feces, saliva)
Excessive concern with environmental contaminants (e.g. asbestos, radiation, toxic wast)
Excessive concern with household items (e.g. cleaners, solvents)
Excessive concern about animals/insects
Excessively bothered by sticky substances or residues
Concerned will get ill because of contaminant
Concerned will get others ill by spreading contaminant (agressive)
No concern with consequences of contamination other than how it might feel*
Other

If other please specify here:

AGGRESSIVE OBSESSIONS:

	Current	Past	Principle
Fear might harm self
Fear might harm others
Fear harm will come to self
Fear harm will come to others (maybe because of something child did or did not do)
Violent or horrific images
Fear of blurting out obscenities or insults
Fear of doing something embarrassing*
Fear will act on unwanted impulses (e.g. to stab a family member)
Fear will steal things
Fear will be responsible for something else terrible happening (e.g. fire, burglary, flood)
Other

If other please specify here:

SEXUAL OBSESSIONS:

	Current	Past	Principle
Forbidden or perverse sexual thoughts, images, impulses
Content involves homosexuality
Sexual behavior towards others (aggressive)
Other

If other please specify here:

HOARDING/SAVING OBSESSIONS:

	Current	Past	Principle
Fear of losing things
Other

If other please specify here:

MAGICAL THOUGHTS/SUPERSTITIOUS OBSESSIONS:

	Current	Past	Principle
Lucky/unlucky numbers , colors, words
Other

If other please specify here:

SOMATIC OBSESSIONS:

	Current	Past	Principle
Excessive concern with illness or disease*
Excessive concern with body part or apect of appearance (e.g. dysmorphophobia)
Other

If other please specify here:

RELIGIOUS OBSESSIONS:

	Current	Past	Principle
Excessive concern or fear of offending religious objects
Excessive concern with right/wrong morally
Other

If other please specify here:

MISCELLANEOUS OBSESSIONS:

	Current	Past	Principle
The need to know or remember
Fear of saying certain things
Fear of not saying just the right thing
Intrusive (non-violent) images
Intrusive sounds, words, music or numbers
Other

If other please specify here:

TARGET SYMPTOM LIST FOR OBSESSIONS: OBSESSIONS (describe, listing by order of severity, with 1 being the most severe, 2 second most severe, etc.)

CY-BOCS Compusions Checklist

Check all symptoms that apply (Items marked * may or may not be OCD Phenomena)

WASHING/CLEANING COMPULSIONS:

	Current	Past	Principle
Excessive or ritualized hand washing
Excessive or ritualized showering, bathing, tooth brushing, grooming, toilet routine
Excessive cleaning of items, such as personal clothes or important objects
Other measures to prevent or remove contact with contaminants
Other

If other please specify here:

CHECKING COMPULSIONS:

	Current	Past	Principle
Checking locks, toys, school books/items, etc.
Checking associated with getting washed, dressed, or undressed
Checking that did not/will not harm others
Checking that did not/will not harm self
Checking that nothing terrible did/will happen
Checking that did not make mistake
Checking tied to somatic obsessions
Other

If other please specify here:

REPEATING RITUALS:

	Current	Past	Principle
Rereading, erasing, or rewriting
Need to repeat activities (e.g. in/out of doorway, up/down from chair)
Other

If other please specify here:

COUNTING COMPULSIONS:

	Current	Past	Principle
Objects, certain numbers, words, etc.
Other

If other please specify here:

ORDERING/ARRANGING:

	Current	Past	Principle
Need for symmetry/evening up (e.g. lining items up a certain way or arranging personal items in specific patterns)
Other

If other please specify here:

HOARDING/SAVING COMPUSIONS: (Distinguish from hobbies and concern with objects of monetary or sentimental value)

	Current	Past	Principle
Difficulty throwing things away, saving bits of paper, string, etc.
Other

If other please specify here:

EXCESSIVE GAMES/SUPERSTITIOUS BEHAVIORS:

	Current	Past	Principle
Distinguish from age appropriate magical games (e.g. array of behavior, such as sleeping over certain spots on a floor, touching an object/self certain number of times as a routine game to avoid something bad from happening)
Other

If other please specify here:

RITUALS INVOLVING OTHER PERSONS:

	Current	Past	Principle
The need to involve another person (usually a parent) in aritual (e.g. asking a parent to repeatedly answer the same question, making mother perform certain mealtime rituals involving specific utensils)*
Other

If other please specify here:

MISCELLANEOUS COMPULSIONS:

	Current	Past	Principle
Mental rituals other than checking/counting
Need to tell, ask or confess
Measures (not checking) to prevent:
Harm to self
Harm to others
Terrible consequences
Ritualized eating behaviors*
Excessive list making*
Need to touch, tap, rub*
Need to do things (e.g. touch or arrange until it feels just right)*
Rituals involving blinking or staring*
Trichotillomania (hair-pulling)
Other self-damaging or self-mutilating behaviors*
Other

If other please specify here:

TARGET SYMPTOM LIST FOR COMPULSIONS: COMPULSIONS (describe, listing by order of severity, with 1 being the most severe, 2 second most severe, etc.)

Obsession Rating Scale

Select appropriate score

Note: Scores should reflect the composite effect of all the patient's obsessive compulsive symptoms. Rate the average occurrence of each item during the prior week up to and including the time of interview.

QUESTIONS ON OBSESSIONS (ITEMS 1-5)

"I am now going to ask you questions about the thoughts you cannot stop thinking about."

(Review for the informant(s) the Target Symptoms and refer to them while asking questions 1-5).

1. Time Occupied by Obsessive Thoughts (Be*

0 - None1 - Mild: Less than 1 hr/day or occasional intrusion2 - Moderate: 1-3 hrs/day or frequent intrusion3 - Severe: Greater than 3 and up to 8 hrs/day or very frequent intrusion4 - Extreme: Greater than 8 hrs/day or near constant intrusion

2. Interference Due to Obsessive Thoughts (How much do these thoughts get in the way of school or doing things with friends? Is there anything that you don't do because of them? {If currently not in school, determine how much performance would be affected if patient were in school})*

0 - None1 - Mild: Slight interference with social or school activities, but overall performance not impaired2 - Moderate: Definite interference with social or school performance, but still manageable3 - Severe: Causes substantial impairment in social or school performance4 - Extreme: Incapacitating

3. Distress Associated with Obsessive Thoughts:*

0 - None1 - Mild: Infrequent and not too disturbing2 - Moderate: Frequent and disturbing, but still manageable3 - Severe: Very frequent, and very disturbing4 - Extreme: Near constant, and disabling distress/frustration

4. Resistance Against Obsessions: (How hard do you try to stop the thoughts or ignore them? {Only rate effort made to resist, not success or failure in actually controlling the obsessions. If the obsessions are minimal, the patient may not feel the need to resist them. In such cases, a rating of "0" should be given})*

0 - None: Makes an effort to always resist, or symptoms so minimal doesn't need to actively resist1 - Mild: Tries to resist most of the time2 - Moderate: Makes some effort to resist3 - Severe: Yields to all obsessions without attempting to control them, but does so with some reluctance4 - Extreme: Completely and willingly yields to all obsessions

5. Degree of Control Over Obsessive Thoughts:*

0 - Complete Control1 - Much Control: Usually able to stop or divert obsessions with some effort and concentration2 - Moderate Control: Sometimes able to stop or divert obsessions3 - Little Control: Rarely successful in stopping obsessions, can only divert attention with difficulty4 - No Control: Experienced as completely involuntary, rarely able to even momentarily divert thinking

Obsession Subtotal (add items 1-5):

Is there anything in this section that you would like to bring to the attention of your provider?

QUESTIONS ON OBSESSIONS (ITEMS 6-10)

"I am now going to ask you questions about the habits you can't stop."

(Review for the informant(s) the Target Symptoms and refer to them while asking questions 6-10).

6. Time Spent Performing Compulsive Behaviors:*

0 - None1 - Mild: Less than 1 hour/day2 - Moderate: 1 to 3 hours/day3 - Severe: Greater than 3 and up to 8 hours/day4 - Extreme: Greater than 8 hours/day

7. Interference Due to Compulsive Behaviors (How much do these habits get in the way of school or doing things with friends? Is there anything you don't do because of them? {If currently not in school, determine how much performance would be affected if patient were in school}):*

0 - None1 - Mild: Slight interference with social or school performance, but still manageable2 - Moderate: Definite interference with social or school performance, but still manageable3 - Severe: Causes substantial impairment in social or school performance4 - Extreme: Incapacitating

8. Distress Associated with Compulsive Behavior (How would you feel if prevented from carrying out your habits? How upset would you become?):*

0 - None1 - Mild: Only slightly anxious if compulsions prevented2 - Moderate: anxiety would mount but remain manageable if compulsions prevented3 - Severe: Prominent and very disturbing increase in anxiety if compulsions interrupted4 - Extreme: Incapacitating anxiety from any intervention aimed at modifying activity

9. Resistance Against Compulsions (How much do you try to fight the habits? {Only rate effort made to resist, not success or failure in actually controlling the compulsions}):*

0 - None: Makes an effort to always resist, or symptoms so minimal doesn't need to actively resist1 - Mild: Tries to resist most of the time2 - Moderate: Makes some effort to resist3 - Severe: Yields to all obsessions without attempting to control them, but does so with some reluctance4 - Extreme: Completely and willingly yields to all obsessions

10. Degree of Control Over Compulsive Thoughts (How strong is the feeling that you have to carry out the habit{s}? When you try to fight them, what happens?):*

0 - Complete Control1 - Much Control: Experiences pressure to perform the behavior, but usually able to exercise voluntary control over it2 - Moderate Control: Moderate control, strong pressure to perform behavior, can control it only with difficulty3 - Little Control: Little control, very strong drive to perform behavior, must be carried to completion, can only delay with difficulty4 - No Control: No control, drive to perform behavior experienced as completely involuntary and overpowering, rarely able to delay activity (even momentarily)

Compulsion Subtotal (add items 6-10):

CY-BOCS Total (add items 1-10):

Is there anything in this section that you would like to bring to the attention of your provider?

Total CY-BOCS Score: Range of severity for patients who have both obsessions and compulsions

0-7 Subclinical

8-15 Mild

16-23 Moderate

24-31 Severe

32-40 Extreme

Provider Notes: