Assessment
Questions 1-38: In the past month - Questions 39-93: In your lifetime
Initials
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1. Little interest or pleasure in doing things?
*
Please Select
Not at all
Several days
More than half the days
Nearly every day
2. Feeling down, depressed, or hopeless?
*
Please Select
Not at all
Several days
More than half the days
Nearly every day
3. Trouble falling or staying asleep, or sleeping too much?
*
Please Select
Not at all
Several days
More than half the days
Nearly every day
4. Feeling tired or having little energy?
*
Please Select
Not at all
Several days
More than half the days
Nearly every day
5. Poor appetite or overeating?
*
Please Select
Not at all
Several days
More than half the days
Nearly every day
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down?
*
Please Select
Not at all
Several days
More than half the days
Nearly every day
7. Trouble concentrating on things, such as reading the newspaper or watching television?
*
Please Select
Not at all
Several days
More than half the days
Nearly every day
8. Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual?
*
Please Select
Not at all
Several days
More than half the days
Nearly every day
9. Thoughts that you would be better off dead, or thoughts of hurting yourself in some way?
*
Please Select
Not at all
Several days
More than half the days
Nearly every day
10. Feeling nervous, anxious, or on edge?
*
Please Select
Not at all
Several days
More than half the days
Nearly every day
11. Not being able to stop or control worrying?
*
Please Select
Not at all
Several days
More than half the days
Nearly every day
12. Worrying too much about different things?
*
Please Select
Not at all
Several days
More than half the days
Nearly every day
13. Trouble relaxing?
*
Please Select
Not at all
Several days
More than half the days
Nearly every day
14. Being so restless that it is hard to sit still?
*
Please Select
Not at all
Several days
More than half the days
Nearly every day
15. Becoming easily annoyed or irritable?
*
Please Select
Not at all
Several days
More than half the days
Nearly every day
16. Feeling afraid, as if something awful might happen?
*
Please Select
Not at all
Several days
More than half the days
Nearly every day
Back
Next
18. Repeated, disturbing memories, thoughts, or images of a stressful experience from the past?
*
Please Select
Not at all
A little bit
Moderately
Quite a bit
Extremely
19. Repeated, disturbing dreams of a stressful experience from the past?
*
Please Select
Not at all
A little bit
Moderately
Quite a bit
Extremely
20. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
*
Please Select
Not at all
A little bit
Moderately
Quite a bit
Extremely
21. Feeling very upset when something reminded you of the stressful experience?
*
Please Select
Not at all
A little bit
Moderately
Quite a bit
Extremely
22. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?
*
Please Select
Not at all
A little bit
Moderately
Quite a bit
Extremely
23. Avoid thinking about or talking about a stressful experience from the past or avoid having feelings related to it?
*
Please Select
Not at all
A little bit
Moderately
Quite a bit
Extremely
24. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?
*
Please Select
Not at all
A little bit
Moderately
Quite a bit
Extremely
25. Trouble remembering important parts of a stressful experience from the past?
*
Please Select
Not at all
A little bit
Moderately
Quite a bit
Extremely
26. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?
*
Please Select
Not at all
A little bit
Moderately
Quite a bit
Extremely
27. Blaming yourself or someone else for the stressful experience or what happened after it?
*
Please Select
Not at all
A little bit
Moderately
Quite a bit
Extremely
28. Having strong negative feelings such as fear, horror, anger, guilt, or shame?
*
Please Select
Not at all
A little bit
Moderately
Quite a bit
Extremely
29. Loss of interest in activities that you used to enjoy?
*
Please Select
Not at all
A little bit
Moderately
Quite a bit
Extremely
30. Feeling distant or cut off from other people?
*
Please Select
Not at all
A little bit
Moderately
Quite a bit
Extremely
31. Feeling emotionally numb or being unable to have loving feelings for those close to you? Or trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
*
Please Select
Not at all
A little bit
Moderately
Quite a bit
Extremely
32. Irritable behavior, angry outbursts, or acting aggressively?
*
Please Select
Not at all
A little bit
Moderately
Quite a bit
Extremely
33. Taking too many risks or doing things that could cause you harm?
*
Please Select
Not at all
A little bit
Moderately
Quite a bit
Extremely
34. Being “super alert” or watchful or on guard?
*
Please Select
Not at all
A little bit
Moderately
Quite a bit
Extremely
35. Feeling jumpy or easily startled?
*
Please Select
Not at all
A little bit
Moderately
Quite a bit
Extremely
36. Trouble falling or staying asleep?
*
Please Select
Not at all
A little bit
Moderately
Quite a bit
Extremely
37. Having difficulty concentrating?
*
Please Select
Not at all
A little bit
Moderately
Quite a bit
Extremely
Back
Next
39. Did a parent or other adult in the household often swear at you, insult you, put you down, or humiliate you? Or act in a way that made you afraid that you might be physically hurt?
*
Please Select
Yes
No
40. Did a parent or other adult in the household often push, grab, slap, or throw something at you? Or ever hit you so hard that you had marks or were injured?
*
Please Select
Yes
No
41. Did an adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way? Or try to or actually have oral, anal, or vaginal sex with you?
*
Please Select
Yes
No
42. Did you often feel that no one in your family loved you or thought you were important or special? Or our family didn’t look out for each other, feel close to each other, or support each other?
*
Please Select
Yes
No
43. Did you often feel that you didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? Or your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
*
Please Select
Yes
No
44. Were your parents ever separated or divorced?
*
Please Select
Yes
No
45. Was your mother or stepmother: often pushed, grabbed, slapped, or had something thrown at her? Or sometimes or often kicked, bitten, hit with a fist, or hit with something hard? Or ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
*
Please Select
Yes
No
46. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
*
Please Select
Yes
No
47. Was a household member depressed or mentally ill or did a household member attempt suicide?
*
Please Select
Yes
No
48. Did a household member go to prison?
*
Please Select
Yes
No
Back
Next
49. Has there ever been a period of time when 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?
*
Please Select
Yes
No
50. Has there ever been a period of time when you were not your usual self and you were so irritable that you shouted at people or started fights or arguments?
*
Please Select
Yes
No
51. Has there ever been a period of time when you were not your usual self and you felt much more self-confident than usual?
*
Please Select
Yes
No
52. Has there ever been a period of time when you were not your usual self and you got much less sleep than usual and found you didn’t really miss it?
*
Please Select
Yes
No
53. Has there ever been a period of time when you were not your usual self and you were much more talkative or spoke faster than usual?
*
Please Select
Yes
No
54. Has there ever been a period of time when you were not your usual self and thoughts raced through your head or you couldn’t slow your mind down?
*
Please Select
Yes
No
55. Has there ever been a period of time when you were not your usual self and you were so easily distracted by things around you that you had trouble concentrating or staying on track?
*
Please Select
Yes
No
56. Has there ever been a period of time when you were not your usual self and you had much more energy than usual?
*
Please Select
Yes
No
57. Has there ever been a period of time when you were not your usual self and you were much more active or did many more things than usual?
*
Please Select
Yes
No
58. Has there ever been a period of time when you were not your usual self and you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
*
Please Select
Yes
No
59. Has there ever been a period of time when you were not your usual self and you were much more interested in sex than usual?
*
Please Select
Yes
No
60. Has there ever been a period of time when you were not your usual self and you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
*
Please Select
Yes
No
61. Has there ever been a period of time when you were not your usual self and spending money got you or your family in trouble?
*
Please Select
Yes
No
62. If you checked YES to more than one of the above, have several of these ever happened during the same period of time?
*
Please Select
Yes
No
N/A
63. How much of a problem did any of these cause you — like being able to work; having family, money, or legal troubles; getting into arguments or fights
*
Please Select
No problem
Minor problem
Moderate problem
Serious problem
64. Have any of your blood relatives (ie, children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?
*
Please Select
Yes
No
65. Has a health professional ever told you that you have manic-depressive illness or bipolar disorder?
*
Please Select
Yes
No
Back
Next
66. Have any of your closest relationships been troubled by a lot of arguments or repeated breakups?
*
Please Select
Yes
No
67. Have you deliberately hurt yourself physically (e.g., punched yourself, cut yourself, burned yourself)? How about made a suicide attempt?
*
Please Select
Yes
No
68. Have you had at least two other problems with impulsivity (e.g., eating binges and spending sprees, drinking too much and verbal outbursts)?
*
Please Select
Yes
No
69. Have you been extremely moody?
*
Please Select
Yes
No
70. Have you felt very angry a lot of the time? How about often acted in an angry or sarcastic manner?
*
Please Select
Yes
No
71. Have you often been distrustful of other people?
*
Please Select
Yes
No
72. Have you frequently felt unreal or as if things around you were unreal?
*
Please Select
Yes
No
73. Have you chronically felt empty?
*
Please Select
Yes
No
74. Have you often felt that you had no idea of who you are or that you have no identity?
*
Please Select
Yes
No
75. Have you made desperate efforts to avoid feeling abandoned or being abandoned (e.g., repeatedly called someone to reassure yourself that he or she still cared, begged them not to leave you, clung to them physically)?
*
Please Select
Yes
No
76. Because of my [problem] (problem is whatever you feel your greatest obstacle is) my ability to work is impaired. ‘0’ means ‘not at all impaired’ and ‘8’ means very severely impaired to the point I can't work.
*
Please Select
0
1
2
3
4
5
6
7
8
77. Because of my [problem] my home management (cleaning, tidying, shopping,cooking, looking after home or children, paying bills) is impaired.
*
Please Select
0
1
2
3
4
5
6
7
8
78. Because of my [problem] my social leisure activities (with other people e.g.parties, bars, clubs, outings, visits, dating, home entertaining) are impaired.
*
Please Select
0
1
2
3
4
5
6
7
8
79. Because of my [problem], my private leisure activities (done alone, such as reading, gardening, collecting, sewing, walking alone) are impaired
*
Please Select
0
1
2
3
4
5
6
7
8
80. Because of my [problem], my ability to form and maintain close relationships with others, including those I live with, is impaired
*
Please Select
0
1
2
3
4
5
6
7
8
81. Do you hear things other people couldn’t hear, such as voices even when no one was around?
*
Please Select
None (0)
Slight (1)
Mild (2)
Moderate (3)
Severe (4)
82. Do you ever feel that someone could hear your thoughts, or that you could hear what another person was thinking?
*
Please Select
None (0)
Slight (1)
Mild (2)
Moderate (3)
Severe (4)
83. Do you ever feel that something or someone is controlling your thoughts or actions?
*
Please Select
None (0)
Slight (1)
Mild (2)
Moderate (3)
Severe (4)
84. Have you had any strange or odd experiences lately that you cannot explain? Or have you felt like you are being watched, followed, or talked about?
*
Please Select
None (0)
Slight (1)
Mild (2)
Moderate (3)
Severe (4)
85. How often did you have a drink containing alcohol in the past year?
*
Please Select
Never
Monthly or less
2 to 4 times per month
2 to 3 times per week
4 or more times per week
86. On days in the past year when you drank alcohol how many drinks did you typically drink?
*
Please Select
0
1
2
3
4
5
6
7
8
9
10+
87. How often did you have 6 or more (for men) or 4 or more (for women and everyone 65 and older) drinks on an occasion in the past year?
*
Please Select
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
88. Do you make yourself sick (throw up) because you feel uncomfortably full?
*
Please Select
Yes
No
89. Do you worry you have lost control over how much you eat?
*
Please Select
Yes
No
90. Have you recently lost more than one stone (approximately 14 pounds) in a 3-month period?
*
Please Select
Yes
No
91. Do you believe yourself to be fat when others say you are too thin?
*
Please Select
Yes
No
92. Would you say you have thoughts and fears about food and weight that dominate your life?
*
Please Select
Yes
No
Please list all medications you are currently taking (name, dosage, frequency, and how long you have been taking it). Include everything - prescribed medications, over-the-counter medications, vitamins, and supplements
*
Have you ever been in any in patient treatments for addictions, eating, anxiety, depression, etc?
*
Submit
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