Hallucinogen Rating Scale
Beginning on the next page is a list of statements referring to the effects of the drug you received. For each statement, please mark the answer that corresponds to the most intensely you experiences that effect during the time period specified. Please mark only one answer for each item; mark the one that seems best, even if none matches your experience exactly. For example, "Visual Effects," if you experienced extremely intense visual effects during the time period, mark "Extreme." Do not worry if your answers to some questions are opposite to others. If two opposite experiences occurred at some point during the time period, answer each one according to what you experienced.
Name
First Name
Last Name
Amount of time between when the drug was administered and feeling an effect
Not applicable, no effect
0-5 second
5-15 seconds
15-30 seconds
30-60 seconds
more than one minute
A "rush"
Not at all
Slightly
Moderately
Very much
Extremely
Location of rush:
Change in salivation
Not at all
Slightly
Moderately
Very much
Extremely
Body feels different
Not at all
Slightly
Moderately
Very much
Extremely
Please describe:
Change in sense of body weight
Not at all
Slightly
Moderately
Very much
Extremely
Feel as if moving/falling/flying through space
Not at all
Slightly
Moderately
Very much
Extremely
Change in body temperature
Not at all
Slightly
Moderately
Very much
Extremely
Electric/tingling feeling
Not at all
Slightly
Moderately
Very much
Extremely
Pressure or weight in chest or abdomen
Not at all
Slightly
Moderately
Very much
Extremely
Physically loose, limber or flexible
Not at all
Slightly
Moderately
Very much
Extremely
Shaky feelings inside
Not at all
Slightly
Moderately
Very much
Extremely
Feel body shake/tremble
Not at all
Slightly
Moderately
Very much
Extremely
Feel heart beating
Not at all
Slightly
Moderately
Very much
Extremely
Feel heart skipping beats or beating irregularly
Not at all
Slightly
Moderately
Very much
Extremely
Nausea
Not at all
Slightly
Moderately
Very much
Extremely
Physically comfortable
Not at all
Slightly
Moderately
Very much
Extremely
Physically restless
Not at all
Slightly
Moderately
Very much
Extremely
Flushed
Not at all
Slightly
Moderately
Very much
Extremely
Urge to urinate
Not at all
Slightly
Moderately
Very much
Extremely
Urge to move bowels
Not at all
Slightly
Moderately
Very much
Extremely
Sexual feelings
Not at all
Slightly
Moderately
Very much
Extremely
Feel removed, detached, separated from body
Not at all
Slightly
Moderately
Very much
Extremely
change in skin sensitivity
Not at all
Slightly
Moderately
Very much
Extremely
Sweating
Not at all
Slightly
Moderately
Very much
Extremely
Headache
Not at all
Slightly
Moderately
Very much
Extremely
Anxious
Not at all
Slightly
Moderately
Very much
Extremely
Frightened
Not at all
Slightly
Moderately
Very much
Extremely
Panic
Not at all
Slightly
Moderately
Very much
Extremely
Self-accepting
Not at all
Slightly
Moderately
Very much
Extremely
Excited
Not at all
Slightly
Moderately
Very much
Extremely
Awe, amazement
Not at all
Slightly
Moderately
Very much
Extremely
Understanding others feeling
Not at all
Slightly
Moderately
Very much
Extremely
Safe
Not at all
Slightly
Moderately
Very much
Extremely
Feel presence of numinous force, higher power , god
Not at all
Slightly
Moderately
Very much
Extremely
Change in feeling about sounds in room
Not at all
Slightly
Moderately
Very much
Extremely
Happy
Not at all
Slightly
Moderately
Very much
Extremely
Sad
Not at all
Slightly
Moderately
Very much
Extremely
Loving
Not at all
Slightly
Moderately
Very much
Extremely
Euphoria
Not at all
Slightly
Moderately
Very much
Extremely
Despair
Not at all
Slightly
Moderately
Very much
Extremely
Feel like crying
Not at all
Slightly
Moderately
Very much
Extremely
Change in feelings of closeness to people in room
Not at all
Slightly
Moderately
Very much
Extremely
Change in "amount" of emotions
Not at all
Slightly
Moderately
Very much
Extremely
Emotions seem different than usual
Not at all
Slightly
Moderately
Very much
Extremely
Feel of oneness with universe
Not at all
Slightly
Moderately
Very much
Extremely
Feel isolated from people and things
Not at all
Slightly
Moderately
Very much
Extremely
Feel reborn
Not at all
Slightly
Moderately
Very much
Extremely
Satisfaction with the experience
Not at all
Slightly
Moderately
Very much
Extremely
Like the experience
Not at all
Slightly
Moderately
Very much
Extremely
How soon you would like to repeat the experience
Never again
Within a year
Within a month
within a week
As soon as possible
Desire for the experience regularly
Not at all
Slightly
Moderately
Very much
Extremely
An odor
Not at all
Slightly
Moderately
Very much
Extremely
Please describe:
A taste
Not at all
Slightly
Moderately
Very much
Extremely
Please describe:
A sound or sounds accompanying the experience
Not at all
Slightly
Moderately
Very much
Extremely
Please describe:
Sense of silence or deep quiet
Not at all
Slightly
Moderately
Very much
Extremely
Sounds in room sound different
Not at all
Slightly
Moderately
Very much
Extremely
Change in distinctiveness of sounds
Not at all
Slightly
Moderately
Very much
Extremely
Auditory synesthesia ("hearing" visual or other non-auditory perception)
Not at all
Slightly
Moderately
Very much
Extremely
Visual effects
Not at all
Slightly
Moderately
Very much
Extremely
Room looks different
Don't know, eyes closed
Not at all
Slightly
Moderately
Very much
Extremely
Change in brightness of objects in room
Don't know, eyes closed
Not at all
Slightly
Moderately
Very much
Extremely
Change in visual distinctness of objects in room
Don't know, eyes closed
Not at all
Slightly
Moderately
Very much
Extremely
Room overlaid with visual patterns
Don't know, eyes closed
Not at all
Slightly
Moderately
Very much
Extremely
Eyes open visual field vibrating or jiggling
Don't know, eyes closed
Not at all
Slightly
Moderately
Very much
Extremely
Visual synesthesia ("seeing" sound or other nonvisual perception)
Not at all
Slightly
Moderately
Very much
Extremely
Visual images, visions, or hallucinations (can include only geometric abstract patterns)
Not at all
Slightly
Moderately
Very much
Extremely
Kaleidoscopic nature of images/visions/hallucinations
Not applicable, none seen
Not at all
Slightly
Moderately
Very much
Extremely
Difference in brightness of visions compared to usual daylight vision
Not applicable, none seen
Not at all
Slightly
Moderately
Very much
Extremely
Predominant colors:
Dimensionality of images/visions/hallucination
Not applicable, none seen
Linear (one-dimensional)
Flat/plana (two- dimensional)
Three-dimensional
Multi- dimensional
Beyond dimensionality
Movement within visions/hallucinations
Not applicable, none seen
Not at all
Slightly
Moderately
Very much
Extremely
Please describe visions/hallucinations:
White light
Not applicable, none seen
Not at all
Slightly
Moderately
Very much
Extremely
Feel as if dead or dying
Not applicable, none seen
Not at all
Slightly
Moderately
Very much
Extremely
Sense of speed
Not applicable, none seen
Not at all
Slightly
Moderately
Very much
Extremely
Deja vu (that you have experienced this exact situation, even with no real memory of it)
Not applicable, none seen
Not at all
Slightly
Moderately
Very much
Extremely
Deja vu (that you have experienced this exact situation, even with no real memory of it)
Not applicable, none seen
Not at all
Slightly
Moderately
Very much
Extremely
Jemais vu (that you will experience this exact situation in the future)
Not applicable, none seen
Not at all
Slightly
Moderately
Very much
Extremely
Contradictory feelings at the same time (happy and sad; hopeful and hopeless)
Not applicable, none seen
Not at all
Slightly
Moderately
Very much
Extremely
Sense of chaos
Not applicable, none seen
Not at all
Slightly
Moderately
Very much
Extremely
Change in strength of sense of self
Not at all
Slightly
Moderately
Very much
Extremely
New thoughts or insights
Not at all
Slightly
Moderately
Very much
Extremely
Memories of childhood
Not at all
Slightly
Moderately
Very much
Extremely
Feel like a child
Not at all
Slightly
Moderately
Very much
Extremely
Change in rate of thinking
Not at all
Slightly
Moderately
Very much
Extremely
Change in quality of thinking
Not at all
Slightly
Moderately
Very much
Extremely
Difference in feeling of reality of experiences compared to everyday experience
Not at all
Slightly
Moderately
Very much
Extremely
Dreamlike nature of the experiences
Not at all
Slightly
Moderately
Very much
Extremely
Thoughts of present or recent past personal life
Not at all
Slightly
Moderately
Very much
Extremely
Insights into personal or occupational concerns
Not at all
Slightly
Moderately
Very much
Extremely
Change in rate of time passing
Not at all
Slightly
Moderately
Very much
Extremely
Unconscious
Definitely not
Not sure
Definitely yes
Change in sense of sanity
Not at all
Slightly
Moderately
Very much
Extremely
Urge to close eyes
Not at all
Slightly
Moderately
Very much
Extremely
Change in effort of breathing
Not at all
Slightly
Moderately
Very much
Extremely
Able to follow the sequence of effects
Not at all
Slightly
Moderately
Very much
Extremely
Able to "let go"
Not at all
Slightly
Moderately
Very much
Extremely
Able to focus attention
Not at all
Slightly
Moderately
Very much
Extremely
In control
Not at all
Slightly
Moderately
Very much
Extremely
Able to move around if asked to do so
Not at all
Slightly
Moderately
Very much
Extremely
Able to remind yourself of being in a research room, being administered a drug, the temporary nature of the experience
Not at all
Slightly
Moderately
Very much
Extremely
Waxing and waning of the experience
Not at all
Slightly
Moderately
Very much
Extremely
Intensity
Not at all
Slightly
Moderately
Very much
Extremely
High
Not at all
Slightly
Moderately
Very much
Extremely
Dose you think you received
Not at all
Slightly
Moderately
Very much
Extremely
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