Severity of Dissociative Symptoms—Adult*

Severity of Dissociative Symptoms—Adult*

*Brief Dissociative Experiences Scale (DES-B)—Modified
Name *

First Name Last Name
Instructions to patient: Instructions: For each statement below, please check () the box that best answers each question to show how much each thing has happened to you in the past SEVEN (7) DAYS.

*

	Not at all 0	Once or twice 1	Almost every day 2	About once a day 3	More than once a day 4
I find myself staring into space and thinking of nothing.
People, objects, or the world around me seem strange or unreal.
I find that I did things that I do not remember doing.
When I am alone, I talk out loud to myself.
I feel as though I were looking at the world through a fog so that people and things seem far away or unclear.
I am able to ignore pain.
I act so differently from one situation to another that it is almost as if I were two different people.
I can do things very easily that would usually be hard for me.

DO NOT COMPLETE (THIS SECTION FOR CLINICIAN)

	ITEM SCORES
TOTAL/PARTIAL RAW SCORE
PRORATED TOTAL RAW SCORE (if 1-2 items left unanswered)
Average Total Score
SEVERITY

Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform