Adult Symptom Screener

Adult Symptom Screener

Please check the box for the answer that best fits your experience
Your Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Date*

MonthDayYear
Date
PART 1: In the last 2 weeks, how often have you been bothered by the following problems?
Feeling down, depressed, or hopeless*

Not at allSeveral daysMore than half the daysNearly every day
Little interest or pleasure in doing things*

Not at allSeveral daysMore than half the daysNearly every day
PART 2: In the last 2 weeks, how often have you been bothered by the following problems?
Feeling nervous, anxious or on edge*

Not at allSeveral daysMore than half the daysNearly every day
Not being able to stop or control worrying*

Not at allSeveral daysMore than half the daysNearly every day
PART 3: The following questions relate to your experience over the last 6 months.
In the past 6 months, did you ever have a spell or an attack when all of sudden you felt frightened, anxious or very uneasy?

YesNo
In the past 6 months, did you ever have a spell or attack when for no reason your heart suddenly began to race, you felt faint, or you couldn’t catch your breath?

YesNo
Did any of these spells or attacks ever happen in a situation when you were not in danger or not the center of attention?

YesNo
PART 4: Please respond to the degree that the following problems have botherd you during the past week.
Fear of embarrassment causes me to avoid doing things or speaking to people.

Not at allA little bitSomewhatVery MuchExtremely
I avoid activities in which am the center of attention.

Not at allA little bitSomewhatVery MuchExtremely
Being embarrassed or looking stupid are among my worst fears.

Not at allA little bitSomewhatVery MuchExtremely
PART 5: Please answer each question to the best of your ability.
Have you experienced any of the following traumatic events: natural disaster (e.g. flood, hurricane, tornado, earthquake), fire, explosion, or industrial accident; transportation accident (e.g. car accident, plane crash); physical assault (e.g. being attacked, beaten up); sexual assault (e.g. rape, attempted rape, made to perform any type of sexual act through force or threat of harm); captivity or exposure to a war-zone; life threatening illness or injury; sudden, unexpected death of or injury to someone close to you; or serious injury, harm, or death to someone else that you witnessed or caused?*

YesNo
Has this event caused any significant problems or symptoms that lasted for more than a month?*

YesNo
PART 6: Please answer each question to the best of your ability.

Has there ever been a period of time where you were not your usual self and...
...you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?*

YesNo
...you were so irritable that you shouted at people or started fights or arguments?*

YesNo
...you felt much more self-confident than usual?*

YesNo
...you got much less sleep than usual and found you didn’t really miss it?*

YesNo
...you were much more talkative or spoke much faster than usual?*

YesNo
...thoughts raced through your head or you couldn’t slow your mind down?*

YesNo
...you were easily distracted by things around you that you had trouble concentrating or staying on track?*

YesNo
...you had much more energy than usual?*

YesNo
...you were much more active or did many more things than usual?*

YesNo
...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?*

YesNo
...you were much more interested in sex than usual?*

YesNo
...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?*

YesNo
...spending money got you or your family into trouble?*

YesNo
PART 7: The following questions relate to your eating habits.
When you eat, do you make yourself sick because you feel uncomfortably full?*

YesNo
Do you ever worry that you have lost control over how much you eat?*

YesNo
Have you recently lost more than 14 pounds in a 3 month period?*

YesNo
Do you believe yourself to be fat when others say you are too thin?*

YesNo
Would you say that food dominates your life?*

YesNo
PART 8: Please answer the following question to the best of your ability.
Have you ever been bothered by having to perform some ritual or act over and over that does not make sense?*

YesNo
PART 9: The following questions relate to your alcohol and substance use.
How often do you have a drink of alcohol?*

NeverMonthly or less2 to 4 times a month2 to 3 times a week4 or more times a week
How many drinks containing alcohol do you have on a typical day when you're drinking?*

1 to 23 to 45 to 67 to 910 or more
How often do you have 6 or more drinks on one occasion?*

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
PART 10: Please answer the following questions to the best of your ability.
In the past year have you used an illegal drug or used a prescription medication for non-medical reasons?*

YesNo
PART 11: Please answer the questions below, rating yourself on each of the criteria shown using the scale provided. As you answer each question, select the option that best describes how you have felt and conducted yourself over the past 6 months.
How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?*

NeverRarelySometimesOftenVery Often
How often do you have difficulty getting things in order when you have to do a task that requires organization?*

NeverRarelySometimesOftenVery Often
How often do you have problems remembering appointments or obligations?*

NeverRarelySometimesOftenVery Often
When you have a task that requires a lot of thought, how often do you avoid or delay getting started?*

NeverRarelySometimesOftenVery Often
How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?*

NeverRarelySometimesOftenVery Often
How often do you feel overly active and compelled to do things, like you were driven by a motor?*

NeverRarelySometimesOftenVery Often
PART 12: The questions listed below relate to your thoughts and feelings. If the way you have been in recent weeks or months differs from the way you usually are, please answer based on when you were your usual self.
Do you find that most people will take advantage of you if you let them know too much about you?*

YesNo
Do you generally feel nervous or anxious around people?*

YesNo
Do you avoid situations where you have to meet new people?*

YesNo
Do you avoid getting to know people because you’re worried that they may not like you?*

YesNo
Has avoidance of getting to know people due to fear of being disliked affected the number of friends that you have?*

YesNo
Do you keep changing the way you present yourself to people because you don’t know who you really are?*

YesNo
Do you often feel like your beliefs change so much that you don’t know what you believe any more?*

YesNo
Do you often get angry or irritated because people don’t recognize your special talents or achievements as much as they should?*

YesNo
PART 13: Please answer the following quuestions to the best of your ability.
Have you had any unusual experiences such as hearing voices, seeing visions, or having ideas you later found out were not true?*

YesNo
Have you had any other experiences, such as mind reading, ESP, thoughts being controlled by others, seeing things on TV that refer to you specifically?*

YesNo
Should be Empty: