Welcome! This survey will assess the kinds of problems you've been having and will help your clinician perform a thorough diagnostic evaluation. It takes about 30-45 minutes to complete and focuses on common problems, such as:

Difficulties in your work or personal relationships
Mood problems such as depression
Anxiety, such as shyness, panic, chronic worrying, and phobias
Reactions to stressful or traumatic events
Pain or other physical symptoms
Addictions to drugs, alcohol, pornography or gaming

Clinical Survey

Part 1. Basic Information

Name *

First Name Last Name

Date of Birth *

1. Gender (Please check one) *

Male Female Other

If other, please explain below:

2. Age (Please check one below) *

0-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81 or older

3. Marital Status (Please check one below) *

a. Single, no partner b. Single, steady partner c. Living Together d. Married e. Separated f. Divorced g. Widowed h. Other

If other, please explain below:

4. Racial Background (Please check one below that applies the best) *

a. White/Caucasian b. Black/African/African-American c. Asian/Asian-America/Filipino d. Chicano/Mexican-American/Hispanic e. Middle-Eastern/Arab/Israeli f. Native American h. Other

If other, please explain below:

5. Education (Please check the highest level reached) *

a. No formal education b. Grammar School c. High School d. Some college or technical training e. College degree f. Some graduate school g. Graduate degree

6. Your family's annual income (Please check one below. Take your best guess if unsure.) *

Part 2. Relationship Survey

Instructions: Please select below to indicate whether you're having problems in any of the following areas. Please answer all of the items.

Have you had any problems: *

No

Maybe

Yes

7. At school?

8. In your work or career?

Have you had any problems or conflicts in your relationships with: *

No

Maybe

Yes

9. Your child or parents?

10. A brother or sister?

11. Your spouse or partner?

12. Any abuse or violence in your relationship with a spouse or partner?

13. Any abuse, violence, or neglect in your childhood?

14. Are you struggling because of the death of a loved one?

Relationship Satisfaction Scale

Instructions: Please indicate how satisfied or dissatisfied you feel about your relationship with your mother.

Please put that person's name below:

Please answer all of the items below: *

0 - Very Dissatisfied

1 - Moderately Dissatisfied

2 - Slightly Dissatisfied

3 - Neutral

4 - Slightly Satisfied

5 - Moderately Satisfied

6 - Very Satisfied

15a. Communication and openness

16a. Resolving Conflicts and arguments

17a. Degree of affection and caring

18a. Intimacy and closeness

19a. Overall satisfaction

Instructions: Please indicate how satisfied or dissatisfied you feel about your relationship with your father.

Please put that person's name below:

Please answer all of the items below: *

0 - Very Dissatisfied

1 - Moderately Dissatisfied

2 - Slightly Dissatisfied

3 - Neutral

4 - Slightly Satisfied

5 - Moderately Satisfied

6 - Very Satisfied

15b. Communication and openness

16b. Resolving Conflicts and arguments

17b. Degree of affection and caring

18b. Intimacy and closeness

19b. Overall satisfaction

Anger Toward Yourself

Instructions: Please indicate below how angry you've been feeling with yourself recently.

Please answer all of the items below: *

0 - Not at all

1 - Slightly

2 - Moderately

3 - A lot

4 - Extremely

20. Frustrated

21. Annoyed

22. Irritated

Anger Towards Others

Instructions: Please indicate how angry you've been feeling with other people recently.

Please answer all of the items below: (Angry Feelings) *

0 - Not at all

1 - Slightly

2 - Moderately

3 - A lot

4 - Extremely

23. Frustrated

24. Annoyed

25. Irritated

Please answer all of the items below: (Violent Urges) *

0 - Not at all

1 - Slightly

2 - Moderately

3 - A lot

4 - Extremely

26. I've had thoughts or fantasies of hurting people.

27. I've had the urge to do something harmful or violent.

28. I intend to do something harmful or violent.

Part 3. Mood Survey

Feelings of Depression Right Now

Instructions: Please indicate how much each item describes how you're feeling right now, at this very moment.

Please answer all of the items below: *

0 - Not at all

1 - Slightly

2 - Moderately

3 - A lot

4 - Extremely

29. Sad or down in the dumps

30. Discouraged or hopeless

31. Low self-esteem, inferiority, or worthlessness

32. Loss of motivation to do things

33. Loss of pleasure or satisfaction in life

Chronic Depression

Instructions: Please indicate below how much each item describes how you've felt in the past two years.

Please answer all of the items below: *

0 - Not at all

1 - Slightly

2 - Moderately

3 - A lot

4 - Extremely

34. I've felt depressed or unhappy on most days for the past two years.

35. I've felt sad, blue, or down most of the time for the past two years.

Previous Episodes of Chronic Depression *

No

Maybe

Yes

36. Was there ever a time in your life when you felt sad, blue, or depressed almost every day for a period of at least two years?

Feelings of Depression During the Past Two Weeks

Major Depression

Instructions: Please indicate how much each item describes how you've been feeling during the past two weeks.

Please answer all of the items below: *

0 - Not at all

1 - Slightly

2 - Moderately

3 - A lot

4 - Extremely

37. I've been feeling down or depressed nearly every day for the past two weeks.

38. I've lost interest in nearly all pleasurable or rewarding activities during the past two weeks.

39. I've been feeling hopeless.

40. Feelings of depression have been distressing or upsetting to me.

41. Feelings of depression have been causing problems in my work, relationships, or activities.

Suicidal Urges During the Past Two Weeks *

0 - Not at all

1 - Slightly

2 - Moderately

3 - A lot

4 - Extremely

42. At times, I've had thoughts or fantasies of killing myself.

43. At times, I've had the urge to commit suicide

Previous Episodes of Major Depression *

No

Maybe

Yes

44. Was there ever a time in your life when you felt sad, blue, or depressed every day for at least two weeks?

Physical Symptoms

Instructions: Please indicate how much each item describes how you've been feeling during the past two weeks.

Please answer all of the items below: *

0 - Not at all

1 - Slightly

2 - Moderately

3 - A lot

4 - Extremely

45. Poor appetite

46. Overeating

47. Trouble Sleeping

48. Sleeping too much

49. Trouble concentrating or making decisions

Dramatically Elevated Mood

Instructions: Please indicate how much each statement describes how you've been feeling recently.

Please answer all of the items below: *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

50. I feel excited and enthusiastic about practically everything.

51. I feel far happier and more cheerful than usual.

52. I've been feeling irritable at times.

53. I've been feeling angry at times.

Mania and Hypomania Checklist

Indicate: Please indicate how much each statement describes how you've been feeling recently.

Please answer all of the items below: *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

54. I've been feeling extremely worthwhile.

55. I've had tremendously high self-esteem.

56. My mind has been flooded with creative, exciting ideas.

57. Almost everything seems to capture my attention.

58. I've had enormous energy.

Current Episode of Mania or Hypomania *

No

Maybe

Yes

59. During the past month, have you felt intensely euphoric or excessively irritable all day long, every day, for at least four days in a row?

60. During the past month, have you felt intensely euphoric or excessively irritable all day long, every day, for at least one week?

61. Were you taking drugs or alcohol when you had these kinds of feelings?

Past Episode of Mania or Hypomania *

No

Maybe

Yes

62. Have you felt intensely euphoric or excessively irritable at any time during your life?

63. Did you feel intensely euphoric or excessively irritable all day long, every day, for at least four days in a row?

64. Did you feel intensely euphoric or excessively irritable all day long, every day, for at least a week?

65. Were you taking drugs or alcohol when you had these symptoms?

Part 4. Anxiety Survey

Anxious Feelings

Instructions: Please indicate how you've been feeling recently.

Please answer all of the items below: *

0 - Not at all

1 - Slightly

2 - Moderately

3 - A lot

4 - Extremely

66. Anxious

67. Nervous

68. Worried

69. Frightened or apprehensive

70. Tense or on edge

Physical Symptoms of Anxiety

Instructions: Please indicate how strong each type of symptom is when you're feeling worried, anxious, or panicky.

Please answer all of the items below: *

0 - Not at all

1 - Slightly

2 - Moderately

3 - A lot

4 - Extremely

71. Skipping, racing, or pounding of the heart

72. Sweating, chills, or hot flushes

73. Trembling or shaking

74. Feeling short of breath or difficulty breathing

75. Feeling dizzy, lightheaded, or off-balance

Chronic Worrying

Instructions: Please indicate how you've been feeling recently.

Please answer all of the items below: *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

76. I worry about things a lot.

77. I tend to worry all day long.

78. I've been worrying about things more than not for the past six months.

79. The worrying is upsetting to me.

80. The worrying makes it hard for me to relax and enjoy life.

Panic Attacks

Instructions: Please indicate how you've been feeling recently.

Please answer all of the items below: *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

81. I have sudden attacks or terror or panic that come from out of the blue.

82. During the panic attacks, I feel like I'm about to die, faint, go crazy, or lose control.

83. During the panic attacks, I have intense physical symptoms, such as dizziness, tingling, racing heart, tight muscles, or feeling short of breath.

84. The panic attacks become absolutely terrifying within ten minutes or less.

85. The panic attacks are upsetting or cause problems in my life.

Specific Fears During Panic Attacks

Instructions: Please indicate how strong each of these feelings is during your panic attacks.

During panic attacks, I feel like I'm about to: *

0 - Not at all

1 - Slightly

2 - Moderately

3 - A lot

4 - Extremely

86. Faint, pass out or have a stroke

87. Have a heart attack or die

88. Smother or suffocate

89. Crack up, go crazy, or lose my mind

90. Lose control

Frequency of Panic Attacks

None

One panic attack

Several

Once a week

Several times a week

Once a day

Several times a day

91. Instructions: Please indicate how many panic attacks you've had in the past month.

Fear of Being Away from Home Alone

Agoraphobia

Instructions: Please indicate how you've been feeling recently.

Please answer all of the items below: *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

92. I'm afraid of being away from home alone.

93. I'm afraid I'll panic if I'm away from home alone.

94. My fear of being away from home alone is upsetting to me.

95. My fear of being away from home alone causes problems in my life.

96. My fear of being away from home alone limits my activities.

Feared Situations

Instructions: Please indicate how strongly you fear each of the following situations.

Please answer all of the items below: *

0 - Not at all

1 - Slightly

2 - Moderately

3 - A lot

4 - Extremely

97. Being in a crowd or standing in line

98. Busy stores, restaurants, theaters

99. Bridges elevators, parking garages, churches, auditoriums, stadiums

100. Open places like a field or street

101. Trains, buses, subways, cars, or boats

Current Episode *

No

Maybe

Yes

102. I've been bothered by fears of being away from home alone during the past month.

103. I've been bothered by fears of being in the situations listed above during the past month.

Screening for Fears and Phobias

Instructions: Please indicate whether any of these fears or phobias bother you.

Please answer all of the items below: *

No

Maybe

Yes

104. Animals: Fear of dogs, rats, snakes, insects bugs

105. Environment: Fear of heights, storms, lightning, water

106. Situations: Fear of flying, driving, public transportation, closed spaces

107. Fear of blood: needles, injury, or gore

108. Other phobias: choking, vomiting, loud sounds, etc...

Distress from Fears and Phobias

Instructions: Please indicate how strongly you're bothered by any fears or phobias from the list you just completed.

Please answer all of the items below: *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

109. My fears or phobias are upsetting and cause problems in my life.

110. I sometimes feel ashamed of my fears or phobias.

111. If I have to face my fears or phobias, it always causes intense anxiety.

Current Episode *

No

Maybe

Yes

112. I've been bothered by fears and phobias in the past month.

Shyness

Instructions: Please indicate how you've been feeling recently.

Please answer all of the items below: *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

113. I often feel shy or anxious in social situations.

114. My shyness in social situations seems excessive.

115. My shyness seems irrational or unreasonable.

116. My shyness is upsetting to me.

117. My shyness causes problems in my work, social life, or other activities.

Current Episode *

No

Maybe

Yes

118. I've been bothered by anxiety or insecurity in social situations during the past month.

Specific Types of Social Anxiety

Instructions: Please indicate how you've been feeling recently.

Shy Bladder Syndrome (Please answer all of the items below) *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

119. I get nervous about having to urinate (pee) in a public restroom.

120. My anxiety about urinating in a public restroom is upsetting to me.

121. I avoid urinating around other people because of my anxiety.

Test Anxiety (Please answer all of the items below) *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

122. I get so nervous about tests that I can barely study or concentrate.

123. I freeze up whenever I have to take a test.

124. My test anxiety is upsetting to me.

Public Speaking Anxiety (Please answer all of the items below) *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

125. Giving a talk in front of a group of people would make me feel nervous.

126. I'm afraid I'd look anxious or foolish if I had to give a talk in front of others.

127. I don't like having to give talks in public.

Performance Anxiety (Please answer all of the items below) *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

128. Performing in front of a group of people would make me feel nervous.

129. Being on a radio or TV show would make me nervous or anxious.

130. Having to perform in a musical or athletic event would make me anxious.

Part 5. Obsession and Compulsions

Obsessive Thoughts

Instructions: Please indicate how you've been feeling recently.

Please answer all of the items below: *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

131. Upsetting or disturbing thoughts go through my head over and over again.

132. Once I get these upsetting thoughts, I can't seem to ignore them or get rid of them.

Instructions: Do you experience any obsessive worry? *

Yes No

If yes, please select all that apply:

If you chose other obsessive thoughts, please explain below:

Compulsive Rituals

Instructions: Please indicate how you've been feeling recently.

Please answer all of the items below: *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

145. I feel a powerful urge to perform certain rituals when I get anxious.

146. I feel like something terrible will happen if I don't perform these rituals.

Do you engage in any compulsive rituals or behaviors? *

Yes No

Please select all that apply:

147. rituals when I groom myself or clean the house 148. counting things 149. doing things in a particular order 150. praying or repeating words silently 151. arranging things in a certain way 152. washing my hands repeatedly 153. repeating certain actions over and over, such as checking to make sure that the doors are locked 154. hoarding things like old newspapers or other objects 155. other rituals

If you chose other rituals, please describe below:

Time Spent on Obsessive Thoughts and Compulsive Rituals *

No Time

5 Minutes or Less

5 - 10 Minutes

10 - 30 Minutes

30 - 60 Minutes

1 - 2 Hours

3 - 5 Hours

More than 5 Hours

156. On average, how much time do you spend each day having obsessive thoughts?

157. On average, how much time do you spend each day doing compulsive behavior?

Distress from Obsessions and Compulsions

Instructions: Please indicate how you feel about your obsessions or compulsions.

Please answer all of the items below: *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

158. My obsessions or compulsions cause problems in my life.

159. My obsessions or compulsions seem excessive.

160. My obsessions or compulsions interfere with my life.

Current Episode *

No

Maybe

Yes

161. I've been bothered by obsessive thoughts during the past month.

162. I've engaged in compulsive rituals during the past month.

Concerns About Your Appearance

Instructions: Please indicate how you've been feeling recently.

Please answer all of the items below:

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

163. I feel like there's something abnormal or grotesque about my appearance.

164. If other people told me that they couldn't see anything wrong with how I look, I wouldn't believe them.

165. I feel upset or embarrassed about my physical appearance.

Part 6. Stressful or Traumatic Events

Instructions: Please list any traumatic or stressful events that have caused emotional problems for you, and indicate how old you were when each event occurred. Even though it may be upsetting, make sure you include any horrifying events, such as rape, abuse, death, violence, torture, or serious illness or injury.

1. *

Please N/A if this doesn't apply 0/1000

Please list your age when this event happened. *

Please put N/A if this doesn't apply

2.

0/1000

Please list your age when this event happened.

3.

0/1000

Please list your age when this event happened.

4.

0/1000

Please list your age when this event happened.

5.

Please list your age when this event happened.

6.

Please list your age when this event happened.

7.

0/1000

Please list your age when this event happened.

8.

0/1000

Please list your age when this event happened.

9.

0/1000

Please list your age when this event happened.

10.

0/1000

Please list your age when this event happened.

Distress from Stressful Events Adjustment Disorder

Instructions: Please indicate how you've been feeling recently.

Please answer all of the items below: *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

166. I've felt down and depressed ever since one of the upsetting events described above.

167. I've been feeling distressed and upset about the stressful event described above.

Post-Traumatic Stress Disorder

Instructions: Please indicate whether you've been exposed to a terrifying, traumatic event, and how you've been feeling since that time.

Please answer all of the items below:

Exposure to a Traumatic Event *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

168. I've experienced or witnessed a terrible, horrific traumatic event such as rape, murder, serious injury, torture, or a threat to my life or someone else's life.

169. I've learned that a traumatic or violent event occurred to a close friend or family member.

170. I've been repeatedly exposed to a traumatic or violent event. (For example, I was a first responder to a bombing, or I've had to investigate many horrible cases of child abuse.)

Persistent Memories of the Event *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

171. Upsetting memories of the traumatic event come into my mind over and over.

172. I have upsetting dreams about the upsetting event.

173. I sometimes have flashbacks and feel like the event is happening again.

174. I get upset whenever I think about the event or whenever I'm reminded of it.

Avoidance *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

175. I try to avoid upsetting thoughts, feelings, or memories of the traumatic event.

176. I try to avoid people, places, objects, conversations, or situations that remind me of the event.

Loss of Interest in Life *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

177. I've lost interest in life.

178. I often feel isolated or alienated from other people.

179. I feel numb and unable to experience love, pleasure, or happiness.

180. I often feel like I have no future.

Duration of PTSD *

Years

Months

181. How long have you experienced these kinds of symptoms? If unsure, just make your best guess.

Current Episode *

No

Maybe

Yes

182. Have you been bothered by these kinds of memories, upsetting feelings, and symptoms during the past month?

Part 7. Somatic Concerns

Health Concerns

Instructions: Please indicate whether you've had any of the following concerns about your health.

Please answer all of the items below: *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

183. I often worry that I have a serious medical problem or disease.

184. I worry about aches, pains, fatigue, dizziness, racing heart, or other symptoms.

185. My worries about my health are upsetting to me.

Current Pain

186. Please indicate the number that shows how much physical pain you feel RIGHT NOW. *

187. Please circle the number that shows how severe your physical pain is RIGHT NOW. *

Recent Pain

188. Please circle the number that shows how much physical pain you've experienced RECENTLY. *

189. Please circle the number that shows how severe your physical pain hes been RECENTLY. *

Emotional Impact of Pain

Instructions: Please indicate how you've been feeling recently.

Please answer all of the items below: *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

190. Physical pain is causing a great deal of emotional distress for me.

191. Physical pain is causing problems in my life.

Part 8. Habits and Addictions

Pornography Screening

Please answer all of the items below: *

No

Maybe

Yes

192. Do you have strong urges to view pornography?

193. Have you felt that excessive pornography use was a problem for you?

Pornography Problems

Instructions: Please indicate how accurately each statement describes how you feel.

Please answer all of the items below: *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

194. I'm preoccupied with pornography.

195. I've tried unsuccessfully to stop or cut down.

196. Pornography is a way of escaping from my personal problems or coping with feelings of unhappiness and stress.

Gaming Screening

Please answer all of the items below: *

No

Maybe

Yes

197. Do you have strong urges to play videogames?

198. Have you ever felt that excessive videogame playing was a problem for you?

Gaming Problems

Instructions: Please indicate how accurately each statement describes how you feel.

Please answer all of the items below: *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

199. I'm preoccupied with "gaming".

200. I've tried to unsuccessfully stop or cut down.

201. Playing video games is a way of escaping from my personal problems or coping with feelings of unhappiness and stress.

Alcohol and Drug Use

Lifetime Alcohol Screening *

No

Maybe

Probably

Definitely

202. Have you ever used alcohol excessively?

203. Have you ever felt that you might have a problem with alcohol?

204. Has anyone ever suggested you have a problem with alcohol?

Lifetime Drug Screening *

No

Maybe

Probably

Definitely

205. Have you ever used drugs excessively?

206. Have you ever felt that you might have a problem with drugs?

207. Has anyone ever suggested you might have a problem with drugs?

Recent Use of Alcohol and Drugs *

No

Maybe

Probably

Definitely

208. Do you feel that you might have used too much alcohol recently?

209. Do you feel that you might have taken too many drugs recently?

Cravings and Urges to Use

Instructions: Please indicate how much each statement describes how you have been feeling in the past week, including today.

Please answer all of the items below: *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

210. Sometimes I crave drugs or alcohol.

211. Sometimes I have the urge to use drugs or alcohol.

212. Sometimes I really want to use drugs or alcohol.

213. Sometimes it's hard to resist the urge to use drugs or alcohol.

214. Sometimes I have to struggle with the temptation to use drugs or alcohol.

Alcohol Consumption in the Past Week

Instructions: Please indicate how often you've used alcohol during the past week. If unsure, take your best guess. *

0 days

1 day

2 days

3 days

4 days

5 - 6 days

Every day

Several times a day

215. Beer, wine, or hard liquor

Please answer all of the items below: *

0 drinks

1 drink or less

2 drinks

3 drinks

4 or 5 drinks

6 - 10 drinks

More than 10 drinks

216. Please indicate the most alcohol you consumed in a single day during the past week.

Note: One drink = 12 ounces of beer; 4 - 5 ounces of wine; or 1.25 ounces of liquor. One cocktail could = 2 or 3 drinks, or more, depending on how much alcohol you put in it.

Alcohol Consumption in the Past Year

Instructions: Think of the time when you were drinking the most during the past year. At that time, how often were you drinking alcohol? If unsure, take your best guess. *

0 days

1 day

2 days

3 days

4 days

5 - 6 days

Every day

Several times a day

217. Beer, wine, or hard liquor

Please answer all of the items below: *

0 drinks

1 drink or less

2 drinks

3 drinks

4 or 5 drinks

6 - 10 drinks

More than 10 drinks

218. Please indicate the most alcohol you consumed in a single day during the past year.

Note: One drink = 12 ounces of beer; 4 - 5 ounces of wine; or 1.25 ounces of liquor. One cocktail could = 2 or 3 drinks, or more, depending on how much alcohol you put in it.

Lifetime Alcohol Consumption

Instructions: Think of the time when you were drinking the most during your life. At that time, how often were you drinking alcohol? If unsure, take your best guess. *

0 days

1 day

2 days

3 days

4 days

5 - 6 days

Every day

Several times a day

219. Beer, wine, or hard liquor

Please answer all of the items below: *

0 drinks

1 drink or less

2 drinks

3 drinks

4 or 5 drinks

6 - 10 drinks

More than 10 drinks

220. Please indicate the most alcohol you consumed in a single day during in your life.

Note: One drink = 12 ounces of beer; 4 - 5 ounces of wine; or 1.25 ounces of liquor. One cocktail could = 2 or 3 drinks, or more, depending on how much alcohol you put in it.

Problems from Alcohol Use

Instructions: Please indicate whether you've had the following kinds of problems because of alcohol.

Please answer all of the items below: *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

221. Have you experienced strong cravings to drink alcohol?

222. Have you ever spent a great deal of time using alcohol?

223. Have you had to take more and more alcohol in order to get high?

224. Has it ever been hard to gut down or stop drinking?

225. Have you ever had problems at home, at school, or at work because of alcohol?

226. Did you ever have problems in your relationships with others because you were drinking?

227. Have you ever had blackouts or forgotten what you did when you were high on alcohol?

228. Have you sometimes used alcohol in physically dangerous situations, such as driving?

229. Have you ever gotten depressed or violent when you were using alcohol?

230. Did you ever experience withdrawal symptoms when you tried to stop drinking?

231. Have you ever continued to drink even though the alcohol was causing emotional problems, health problems, legal problems, relationship problems, or other problems?

Have you ever had a DUI? *

Yes No

If yes, how many?

What Year?

Drug Use during the Past Week

Instructions: Please indicate how often you've used drugs during the past week. If unsure, take your best guess. Indicate any use of drugs, even if prescribed.

Please answer all of the items below: *

0 days

1 day

2 days

3 days

4 days

5 - 6 days

Every day

Several times a day

232. Marijuana or hashish

233. Cocaine or crack

234. Speed (Ice, crank, crystal amphetamines, meth, uppers)

235. Diet pills or other stimulants

236. Downers (Valium, reds, sedatives, sleeping pills)

237. Opiates (heroin, codeine, Percodan, Demerol)

238. Hallucinogens (acid, LSD, mushrooms, PCP)

239. Glue, spray paint, inhalants

240. Other drugs (Ecstasy, PCP, designer drugs)

Lifetime Drug Use

Instructions: Please indicate how often you've used drugs during your lifetime. Think of the time when you were using each type of drug the most. If unsure, take your best guess. Indicate any use of drugs, even if prescribed.

Please answer all of the items below: *

Never

Less than a month

Once a month

Several times a month

Once a week

Several times a week

Once a day

Several times a day

241. Marijuana or hashish

242. Cocaine or crack

243. Speed (Ice, crank, crystal amphetamines, meth, uppers)

244. Diet pills or other stimulants

245. Downers (Valium, reds, sedatives, sleeping pills)

246. Opiates (heroin, codeine, Percodan, Demerol)

247. Hallucinogens (acid, LSD, mushrooms, PCP)

248. Glue, spray paint, inhalants

249. Other drugs (Ecstasy, PCP, designer drugs)

Problems from Drug Use

Instructions: Please indicate whether you've had the following kinds of problems because of drugs.

Please answer all of the items below: *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

250. Have you experienced strong cravings to use drugs?

251. Have you ever spent a great of time using drugs?

252. Have you had to take more and more drugs in order to get high?

253. Has it ever been hard to cut down or stop using drugs?

254. Have you ever had problems at home, at school, or at work because of drugs?

255. Did you ever have problems in your relationships with others because you were using drugs?

256. Have you ever had blackouts or forgotten what you did when you were high on drugs?

257. Have you sometimes used drugs in physically dangerous situations, such as driving?

258. Have you ever gotten depressed or violent when you were using drugs?

259. Did you ever experience withdrawal symptoms when you tried to stop using drugs?

260. Have you ever continued to use drugs even though they were causing emotional problems, health problems, legal problems, relationship problems, or other problems?

Part 9. Eating Problems

Screening for Eating Disorders *

No

Maybe

Yes

261. Has anyone ever suggested that you had an eating disorder?

262. Have you ever thought that you had an eating disorder?

263. How tall are you? *

Example: 6 ft 3 in

264. How much do you actually weigh? (Actual Weight) *

Overeating Screening *

No

Maybe

Yes

265. Have you ever had a problem with overeating?

266. Have you ever had a problem with binge eating?

Binge Eating

Instructions: Please indicate how much you agree with each of the following statements.

Please answer all of the items below:

Urges to Binge *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

267. Sometimes it's hard to resist the urge to overeat.

268. Sometimes I struggle with the temptation to overeat.

Loss of Control *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

269. I can't seem to control how much I eat.

270. Once I start, I can't seem to stop eating.

Emotional Consequences *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

271. I often feel guilty when I eat too much.

272. I often feel disgusted with myself when I eat too much.

Frequency of Binging and Overeating

Instructions: Please indicate how often you engage in each activity. *

Never

Less than once a month

Once a month

Several times a month

Once a Week

Twice a Week

Once a day

Several times a day.

273. Binging

274. Overeating

Bulimia

Instructions: Please indicate how much you agree with each of the following statements.

Please answer all of the items below:

Purging *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

275. I sometimes vomit after I eat so that I won't gain weight.

276. I sometimes binge and then vomit so I won't gain weight.

Restricting *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

277. I skip meals to avoid gaining weight.

278. I sometimes avoid eating for more than a day to avoid gaining weight.

279. I restrict calories while eating to avoid gaining weight.

280. I exercise a great deal to avoid gaining weight.

Diet Pills *

No

Maybe

Yes

281. I sometimes take diet pills or stimulants to reduce my cravings for food.

Frequency

Instructions: Please indicate how often you engage in each activity to avoid gaining weight. *

Never

Under once a month

Once a month

Several times a month

Once a week

Twice a week or more

Once a day

Several times a day

282. Taking diet pills or stimulants

283. Vomiting after you eat

284. Using enemas

285. Using laxatives or diuretics

286. Skipping meals

287. Restricting calories while eating

288. Exercising a great deal

Anorexia Screening *

No

Maybe

Yes

289. Was there ever a time in your life when you were very thin or weighed much less than people thought you should?

290. Was there ever a time when people told you that you were too thin or weighed much less than people thought you should?

Anorexia

Instructions: Please indicate how much you agree with each of the following statements.

Please answer all of the items below:

Fears of Gaining Weight *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

291. I have intense fears of gaining weight.

292. I'm afraid of slipping up and losing control of my eating.

293. I'm afraid that if I gained even a little weight, my eating would spiral out of control.

Messages from Others *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

294. Others tell me that I need to gain weight.

295. Others tell me that I'm too thin.

Part 10. Other Symptoms

Dissociative Experiences

Instructions: Please indicate how much you agree with each of the following statements.

Please answer all of the items below: *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

296. I sometimes forget where I've been for long periods of time.

297. Sometimes people tell me that they've seen me doing things that I cannot recall.

Unusual Experiences

Instructions: Please indicate below how much you agree with each of the following statements.

Please answer all of the items below:

Special Experiences *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

298. I believe that people are trying to control me with electricity, radio waves, or other forces.

299. I've been receiving special messages from the radio or TV.

Feelings of Mistrust *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

300. I believe that people are saying bad things about me.

301. I believe people want to harm me or take advantage of me.

Feelings of Superiority *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

302. I sometimes feel like I have special powers.

303. I sometimes feel like a Messiah or God.

Personality

Cluster A

Suspicious Feelings

Instructions: Please indicate how much each statement describes how you have felt or behaved most of your life since your teenage years.

Please answer all of the items below: *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

304. I often doubt the loyalty of friends or associates.

305. I don't often confide in people because they may turn against me.

306. I don't want people to find out too much about me because they might use the information against me.

307. I often feel like people are threatening or insulting me.

308. Sometimes I feel like people are out to get me.

Feeling of Isolation

Instructions: Please indicate how much each statement describes how you have felt or behaved most of your life since your teenage years.

Please answer all of the items below: *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

309. I don't get much satisfaction from relationships with other people.

310. There's almost no one I really feel close to.

311. I prefer to do things alone.

312. I usually keep to myself.

313. I usually prefer to be alone.

Unique Experiences

Instructions: Please indicate how much each statement describes how you have felt or behaved most of your life since your teenage years.

Please answer all of the items below:

Supernatural Experiences *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

314. I've had experiences that seemed supernatural.

315. Sometimes I feel like other people can read my mind.

316. Sometimes I feel like there's a person or supernatural force around me, even though nobody seems to be there.

Social Discomfort *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

317. My interactions with others often feel awkward.

318. I usually feel anxious or uncomfortable when I'm around other people.

319. I usually don't fit in with groups of other people.

Cluster B

Wild Tendencies

Instructions: Please indicate how much each statement describes how you have felt or behaved most of your life since your teenage years.

Please answer all of the items below: *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

320. I sometimes break the law.

321. I've done many things I could be arrested for if I got caught.

322. I often do wild or reckless things on the spur of the moment.

323. I've often done risky things, like driving recklessly when intoxicated.

324. I often do things without worrying about harmful consequences.

Problems Growing Up

Instructions: Please indicate if you had any of the following kinds of problems or urges prior to age 15 when you were growing up.

Please answer all of the items below: *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

325. Broke the law or did things that were illegal.

326. Got into trouble with my parents or the authorities.

327. Lied or conned people.

Turbulent Tendencies

Instructions: Please indicate how much each statement describes how you have felt or behaved most of your life since your teenage years.

Please answer all of the items below: *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

328. I often feel worthless.

329. I often feel like I'm defective.

330. I sometimes have trouble controlling my impulsive behavior.

331. I sometimes cut, scratch, or burn myself, or hurt myself in other ways.

332. I almost always have intensely negative moods.

333. I go from one bad mood to another. I often feel hurt, then angry, then jealous, then guilty, then anxious, then depressed, etc...

334. I feel terrified about being abandoned by others.

335. I sometimes feel distrustful toward other people.

336. I often feel angry and bitter.

337. I have difficulties controlling my feelings of anger or bitterness.

Dramatic Tendencies

Instructions: Please indicate how much each statement describes how you have felt or behaved most of your life since your teenage years.

Please answer all of the items below: *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

338. I like to express my feelings in a colorful, dramatic way.

339. I like to express my feelings in a strong, exciting way.

340. Some people might think I'm overly dramatic.

Feelings of Importance

Instructions: Please indicate how much each statement describes how you have felt or behaved most of your life since your teenage years.

Please answer all of the items below: *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

341. I sometimes have a tremendous sense of my own importance or talents.

342. I have fantasies of unlimited success, power brilliance, beauty, or love.

343. I think a lot about power, fame, or recognition.

344. I sometimes feel like I'm extremely special.

Cluster C

Avoidant Tendencies

Instructions: Please indicate how much each statement describes how you have felt or behaved most of your life since your teenage years.

Please answer all of the items below: *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

345. I feel tremendously shy and insecure in social situations.

346. I often feel ashamed or embarrassed in social situations.

347. I sometimes feel like I'm inadequate and unappealing to others.

348. I feel awkward or inept in social situations.

349. I'm afraid that people will look down on me in social situations.

Dependent Tendencies

Instructions: Please indicate how much each statement describes how you have felt or behaved most of your life since your teenage years.

Please answer all of the items below:

Need for Help *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

350. I have trouble doing things on my own without someone else to help me.

351. I don't feel confident that I can do things very well when I'm alone.

352. It's hard for me to initiate new projects on my own.

Conflict Phobia *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

353. I feel worthless when someone criticizes me or disapproves of me.

354. If others disapproved of me or criticized me, I'd feel devastated.

355. I can't stand criticism or disapproval.

Fear of Being Alone *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

356. I don't like to be alone.

357. I can't feel happy or fulfilled when I'm alone.

358. I feel helpless and uncomfortable when I'm alone.

Perfectionist Tendencies

Instructions: Please indicate how much each statement describes how you have felt or behaved most of your life since your teenage years.

Please answer all of the items below: *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

359. I often feel like I have to be perfect.

360. I get very self-critical whenever I fail to achieve my goals.

361. I beat up on myself whenever I make mistakes.

362. Sometimes I get so perfectionistic that I can't finish things.

363. If I failed at my work, I'd feel like a failure as a human being.

Willingness Scale

Instructions: Below you'll find a list of things people do try to overcome feelings of depression and anxiety. Indicate whether you'd be willing to try each activity if a therapist or trusted friend suggested it.

Please answer all of the items below:

In order to recover, I'd be willing to: *

0 - Definitely not

1 - Slightly willing

2 - Moderately willing

3 - Very willing

4 - Extremely willing

364. Try new ways of relating to other people

365. Get started on a task I've been avoiding or putting off

366. Make a plan for solving the problems in my life

367. Face a problem I've been avoiding.

368. Confront my fears, even if it makes me very anxious

369. How many days per week would you be willing to do psychotherapy homework, if suggested? *

0 days/week 1 day/week 2 days/week 3 days/week 4 days/week 5 days/week 6 days/week 7 days/week

370. How many minutes per day would you be willing to do psychotherapy homework, if suggested? *

0 min/day 1 - 2 min/day 5 min/day 10 min/day 20 min/day 30 min/day 1 hour/day More than 1 hour/day

371. How long would you be willing to continue doing psychotherapy treatment, if suggested? *

0 weeks 1 week 2 weeks 3 weeks 1 month 2 months 3 months As long as it takes

Psychotherapy Homework

Instructions: Indicate how strongly you agree with each of the following statements.

Please answer all of the items below: *

0 - Do not Agree

1 - Agree Slightly

2 - Agree Moderately

3 - Strongly Agree

4 - Agree Completely

372. I'm willing to do psychotherapy homework even if I am not in the mood.

373. I'm willing to do psychotherapy homework even if I feel hopeless or unmotivated.

374. I'm willing to do psychotherapy homework even if I feel overwhelmed or tired.

If you agree with the following statement, it indicates that you do NOT want to do psychotherapy homework. *

0 - Do not Agree

1 - Agree Slightly

2 - Agree Moderately

3 - Strongly Agree

4 - Agree Completely

375. I would prefer a form of therapy that does not require psychotherapy homework.

Feelings about the Survey

Instructions: Please indicate how well each statement describes your feelings about this survey.

Please answer all of the items below:

Openness and Accuracy *

0 - Not at all true

1 - Slightly true

2 - Moderately true

3 - Very true

4 - Completely true

376. It was hard to answer some of the questions honestly.

377. It was hard to be completely open when I answered some questions.

Please page through the survey and fill in any items you might have skipped or overlooked. *

No

Yes

378. I have aged through the test to check for any items that I might have missed or skipped.

379. There are one or more items on the survey that I skipped or did not answer.

Congratulations! You've completed the survey. Thank you!

Diagnostic Survey