{"aaData": [["1", "
\nFacial and Oral Movements\n \n \nMuscles of facial expression,\ne.g., movements of forehead, eyebrows, periorbital area, cheeks. Include\nfrowning, blinking, grimacing of upper face.\n \n\n
\nGlobal Judgments\n \nPatient's awareness of abnormal movements.\nRate only patient's report\n \n\n
\nDoes drinking help you to be more alert mentally?\n \n \n\n
\nI want you to . . .\nengage more in activities with me.\n\n
\nYou want me to . . .\nallow you more freedom.\n\n
\nYou want me to . . .\ndisplay more affection for you.\n\n
\nYou want me to . . .\nhave more respect for your judgment.\n\n
\nYou want me to . . .\nfeel more attached to you.\n\n
\nYou want me to . . .\ntreat you in a warmer and friendlier manner.\n\n
\nYou want me to . . .\nbe more interested in your activities.\n\n
\nYou want me to . . .\ntake you out more.\n\n
\nYou want me to . . .\nfeel more confident about your ability to think critically.\n\n
\nYou want me to . . .\nallow you to make more decisions.\n\n
\nDo you drink to change your mood (drink when bored, angry, flat)?\n \n \n\n
\nYou want me to . . .\ndisplay more love for you.\n\n
\nYou want me to . . .\nfeel more strongly that you are a significant aspect of my life.\n\n
\nYou want me to . . .\nhave more respect for your ability to think for yourself.\n\n
\nYou want me to . . .\nshare more of my recreational time with you.\n\n
\nYou want me to . . .\ntell you what to do less often.\n\n
\nYou want me to . . .\nbe more interested in you.\n\n
\nYou want me to . . .\nbe warmer and closer in my behavior toward you.\n\n
\nYou want me to . . .\nfeel more strongly that you are an important member of my group.\n\n
\nYou want me to . . .\nhave more confidence in your ability to learn things.\n\n
\nYou want me to . . .\nspend more time with you.\n\n
\nHave you used alcohol to overcome physical pain?\n \n \n\n
\nYou want me to . . .\ngive you more freedom to choose your own friends.\n\n
\nYou want me to . . .\nbe more interested in the things you are interested in.\n\n
\nYou want me to . . .\nspend more time alone with you.\n\n
\nYou want me to . . .\nput fewer limits on what you can do.\n\n
\nYou want me to . . .\ngive you more praise for your accomplishments.\n\n
\nYou want me to . . .\nbe more confident that you will succeed in life.\n\n
\nYou want me to . . .\ngive you more attention.\n\n
\nYou want me to . . .\nfeel more love for you.\n\n
\nYou want me to . . .\nbe more interested in being at home with you.\n\n
\nYou want me to . . .\nhave more confidence in your ability to take care of yourself.\n\n
\nDo most of your friends drink?\n \n \n\n
\nYou want me to . . .\nallow you to think more for yourself.\n\n
\nYou want me to . . .\nfeel closer to you as a person.\n\n
\nYou want me to . . .\nfeel more strongly that you are a significant person.\n\n
\nYou want me to . . .\nhave more respect for your ability to solve problems.\n\n
\nYou want me to . . .\ntake you more on trips.\n\n
\nYou want me to . . .\ncriticize you less for your conduct and manners.\n\n
\nYou want me to . . .\nfeel more strongly that you are an important person.\n\n
\nYou want me to . . .\nfeel more confident about your ability to succeed at difficult tasks.\n\n
\nYou want me to . . .\nspend more of my free time with you.\n\n
\nYou want me to . . .\nsupervise your activities less.\n\n
\nWhen you drink, do you usually drink alone?\n \n \n\n
\nYou want me to . . .\nfeel more affection for you.\n\n
\nYou want me to . . .\nbe more confident that you can be trusted with responsibilities.\n\n
\nYou want me to . . .\nspend more time showing you how to do things.\n\n
\nYou want me to . . .\nInsist less on respect from you.\n\n
\nYou want me to . . .\nfeel more warmth for you.\n\n
\nYou want me to . . .\nengage more in activities with you.\n\n
\nI feel very tense when I think about the day's events.\n\n
\nI am not a very spiritual person.\n\n
\nI get extremely anxious when I don't know what the doctors are going to do to me.\n\n
\nI am a dramatic kind of person.\n\n
\nDo you panic because you fear you may not have a drink when you need it?\n \n \n\n
\nSometimes I can't remember what medications to take and when to take them\n\n
\nI often get confused about what is happening to me.\n\n
\nI can no longer do things I enjoyed doing in the past.\n\n
\nI've felt sad much of life.\n\n
\nThe idea of being left alone in life really frightens me.\n\n
\nSometimes I take medications that were prescribed for others on the chance that they'll help me.\n\n
\nI wish other people were more accepting of me.\n\n
\nI can get nasty with people who deserve it.\n\n
\nMy best years are behind me.\n\n
\nI feel jumpy and under strain, but I don't know why.\n\n
\nWhen you drink, do you drink every day at about the same time?\n \n \n\n
\nI get great comfort from my religious beliefs.\n\n
\nI begin to cry when the smallest things go wrong.\n\n
\nI seem to fit in right away with any group of people I meet.\n\n
\nI like to follow instructions and do what others expect of me.\n\n
\nMost people wouldn't care much if I were sick.\n\n
\nMedical instruments really frighten me.\n\n
\nLoss of memory has been a big problem for me.\n\n
\nI can't move around and do things as well as I could in the past.\n\n
\nI want my doctor to review with me the results of all my medical tests.\n\n
\nI've found that this society is too hard on people who don't conform.\n\n
\nWhen you drink, do you drink several days and then sober up\nfor a period of time before drinking again?\n \n \n\n
\nI've felt all alone for a very long time now.\n\n
\nI'll stop anyone who tries to boss me around.\n\n
\nI would much rather follow someone than be the leader.\n\n
\nI get very anxious when I think about my medical problems.\n\n
\nI deserve many of the misfortunes I've suffered.\n\n
\nI think things will get much worse in the coming months.\n\n
\nI can't take care of myself as well as I used to.\n\n
\nI try to learn as much as I can about the treatments available for my condition.\n\n
\nFaith and prayer always get me through my troubles.\n\n
\nI have a lot of confidence in myself.\n\n
\nDo you get belligerent or mean when you drink?\n \n \n\n
\nI'm trying to be as open as I can in my responses to these questions.\n\n
\nI protect myself by not letting people know much about my life.\n\n
\nI guess I've always been a fearful and inhibited person.\n\n
\nIf you don't have something good to say about yourself, you should keep quiet.\n\n
\nI would do anything to stop the pain I feel.\n\n
\nI seem to need a lot of advice in order to get things done.\n\n
\nIf I have to go through another medical procedure, I think I'll\njust go crazy.\n\n
\nMy health seems to be failing faster than that of most people my age.\n\n
\nLife will never be the same again for me.\n\n
\nNo matter what, seeing a doctor is reassuring.\n\n
\nHow long were you unemployed during the last year because of drinking?\n \n \n\n
\nI rarely find the time to exercise.\n\n
\nI feel so jittery and restless that I'm worn out at night.\n\n
\nI've always preferred to have a quiet and inactive life.\n\n
\nI have a habit of making my problems sound worse than they really are.\n\n
\nI have been having serious thoughts about suicide.\n\n
\nI like to arrange things down to the last detail.\n\n
\nThere's little emotional support within my family.\n\n
\nI have always had a talent for being successful.\n\n
\nI have told lies to my family to conceal my use of drugs.\n\n
\nVery few people appreciate just how hard my life really is.\n\n
\nDental Status\n \nCurrent problems with teeth and/or dentures.\n \n\n
\nAs a result of being drunk, has your thinking been fuzzy or unclear?\n \n \n\n
\nI seem to be losing my ability to concentrate.\n\n
\nAnswering questions like these helps me take a good honest look at things In my life.\n\n
\nI watch out for people trying to cheat me.\n\n
\nThe pain I'm in has made my life feel very hopeless.\n\n
\nIn this world you either push or get shoved.\n\n
\nI'm very erratic, changing my feelings all the time.\n\n
\nWhen people are bossy, I usually do the opposite of what they want.\n\n
\nI've had nightmares about medical procedures I may have to endure.\n\n
\nI worry a lot that the people I depend on will leave me.\n\n
\nI'm my own worst enemy.\n\n
\nHave you had a convulsion (fit) following a period of drinking?\n \n \n\n
\nI sometimes exaggerate how poorly I am feeling.\n\n
\nFor some unknown reason, I suddenly get very panicky.\n\n
\nMy emotions don't seem to be as strong as other people's.\n\n
\nIt makes me very uncomfortable when other people know about my problems.\n\n
\nPhysical pain is a big part of my life.\n\n
\nI am constantly worried about my health.\n\n
\nIt is good to have a routine for doing things in order to avoid mistakes.\n\n
\nThere is someone close to me who truly understands my feelings.\n\n
\nMany people respect and envy me.\n\n
\nTaking drugs has been a regular part of my social life.\n\n
\nHave you had stomach pains or disruptions of digestion that continued\nfor several days (4 days to over a week)?\n \n \n\n
\nI believe something is wrong with my head.\n\n
\nMost people in my life eventually disappoint me.\n\n
\nI feel particularly resentful when I am refused medical benefits I know I am entitled to.\n\n
\nIt's all right to bend the law as long as you don't break it.\n\n
\nI never let anyone get the better of me.\n\n
\nI know from the past that good things don't last.\n\n
\nI can handle the worst medical news about myself, no matter how upsetting It may be.\n\n
\nI am afraid that I may suddenly die from an illness.\n\n
\nI am quickly losing hope that I will ever regain my health.\n\n
\nI make sure that I'm on time for all my doctor's appointments.\n\n
\nWhen drinking, how much hard liquor (whiskey, vodka, gin) do you\ndrink per day?\n \n \n\n
\nPain makes it very difficult for me to work now.\n\n
\nI have found very few things in life to be pleasurable.\n\n
\nI have many very good and close friends.\n\n
\nI always finish my work before I take time out for leisure.\n\n
\nI have friends who will listen to any problem I have.\n\n
\nEverything I try comes easily to me.\n\n
\nI'm making myself seem healthier in my responses here than I really am.\n\n
\nMy life has always gone from bad to worse.\n\n
\nI think it's best not to trust anyone.\n\n
\nPain is the worst part of my medical condition.\n\n
\nDoes your drinking cause hardships for your family and/or friends?\n \n \n\n
\nI often resent doing things that others expect of me.\n\n
\nI am mistreated most by close friends and relatives.\n\n
\nI quickly consult my doctor whenever I have new symptoms.\n\n
\nI'm on edge a lot lately.\n\n
\nI am never alone as long as God is with me.\n\n
\nI think I'm a very sociable and outgoing person.\n\n
\nIt is always best to follow the rules that those in authority have made.\n\n
\nA lot of my answers on this test have been affected by my current bad mood.\n\n
\nI sometimes take medications that are prescribed for other people.\n\n
\nI often set myself up to fail.\n\n
\nHave you used antabuse to help you to stop drinking?\n \n \n\n
\nI feel guilt most of the time.\n\n
\nI flew across the Atlantic more than 30 times last year.\n\n
\nMy feelings toward my relatives often swing back and forth from love to hate.\n\n
\nI want my doctors to be as detailed as possible in telling me about my medical problems.\n\n
\nI don't think I'll live as long as I should.\n\n
\nI make my life worse than it has to be.\n\n
\nI smoke about a pack of cigarettes a day.\n\n
\nI've never had as much interest in sex as most people my age.\n\n
\nI'm too embarrassed to admit my problems as frankly as I should.\n\n
\nI can charm people into doing almost anything I want.\n\n
\nHave recent notable events made you feel a need for help?\n \n \n\n
\nI've been overweight ever since I was a child.\n\n
\nIf I don't get relief from medicine, I may increase the dosage on my own.\n\n
\nIn the past year, I've really gone downhill mentally.\n\n
\nI think I am making my life look worse than it really is by my responses here.\n\n
\nI spend much of my time brooding about things.\n\n
\nToo many rules get in the way of people doing what they want to do.\n\n
\nNo one needs to know my business.\n\n
\nI've always felt that most people think poorly of me.\n\n
\nI'm considered a tough and unsentimental person.\n\n
\nI was on the front cover of several magazines recently.\n\n
\nWhen drinking, are you able to regulate or control the amount you drink?\n \n \n\n
\nI get very annoyed when others put pressure on me.\n\n
\nMy body is constantly giving me worrisome signals.\n\n
\nIt is difficult for me to get through the day without a few drinks.\n\n
\nI never put off seeing the doctor if I feel I need to.\n\n
\nBeing in touch with my spiritual self helps me deal with life's burdens.\n\n
\nI often feel sad and unloved.\n\n
\nI start feeling crazy when medical problems turn out badly for me.\n\n
\nI am holding back when I respond to many of these statements.\n\n
\nI feel entitled to all my sick days each year.\n\n
\nI'd rather not know the details of an illness I might have.\n\n
\nDoes drinking help you to overcome feelings of inferiority?\n \n \n\n
\nI get very irritable if haven't had a cup of coffee for a few hours.\n\n
\nThe quality of my life has gotten much worse because of my illness.\n\n
\nI rarely feel a sense of joy these days.\n\n
\nI usually do what I want without worrying about how it affects others.\n\n
\nI'm a yo-yo dieter, my weight goes up and down.\n\n
\nMy head often hurts so much that I need to take time off from work.\n\n
\nThis is a very lonely world.\n\n
\nI've tried to quit smoking many times, but I always start again.\n\n
\nI would change my lifestyle on my doctor's advice.\n\n
\nWithout God in my life I could never get through a serious illness.\n\n
\nDo you have better ideas when drinking?\n \n \n\n
\nMy pain is on my mind constantly.\n\n
\nI always overeat when I'm depressed or under stress.\n\n
\nMy future looks like it will be full of problems and pain.\n\n
\nIt's okay to take advantage of gray areas in the law.\n\n
\nI've tried exercise programs, but I just can't seem to stick with them.\n\n
\nI'm unable to organize my life the way I want.\n\n
\nMembers of my family have complained recently about my drinking.\n\n
\nI really don't understand human feelings like others do.\n\n
\nI need plenty of caffeine to get through the day.\n\n
\nI almost always put other people's needs above my own.\n\n
\nDental Status\n \nDoes patient usually wear dentures?\n \n\n
\nDo you drink to manage mood swings from periods\nof happiness to periods of despair?\n \n \n\n
\nI often feel overwhelmed by minor responsibilities.\n\n
\nI've lost interest in things that I used to find pleasurable.\n\n
\nI now need to follow routines so that I don't get confused.\n\n
\nMy medical condition has made daily tasks much more difficult.\n\n
\nI know I should exercise, but I just can't get started.\n\n
\nI cannot count on anyone to support me during times of illness.\n\n
\nI feel very depressed.\n\n
\nI am a very emotional person.\n\n
\nI like to flirt with members of the opposite sex.\n\n
\nI get irritable if I go too long without a cigarette.\n\n
\nHave you used alcohol to deal with stomach/abdominal pain?\n \n \n\n
\nI have no deep religious beliefs.\n\n
\nI always follow my own ideas rather than do what others expect of\nme.\n\n
\nI've always found it more comfortable to do things quietly\nalone instead of with others.\n\n
\nTalking to other people has almost always been difficult and\npainful for me.\n\n
\nI believe in being strong willed and determined in everything I\ndo.\n\n
\nIn the last few weeks I begin to cry even when the slightest of\nthings goes wrong.\n\n
\nSome people think of me as a conceited and self-centered person.\n\n
\nAs a teenager, I got into lots of trouble because of bad school\nbehavior.\n\n
\nI always feel I am not wanted in a group.\n\n
\nI often criticize people strongly if they annoy me.\n\n
\nDoes your social life require you to drink?\n \n \n\n
\nI am content to be a follower of others.\n\n
\nI enjoy doing so many different things that I can't make up my\nmind what to do first.\n\n
\nSometimes I can be pretty rough and mean in my relations with\nmy family.\n\n
\nI have little interest in making friends.\n\n
\nI think I am a very sociable and out-going person.\n\n
\nI know I'm a superior person, so I don't care what people think.\n\n
\nPeople have never given me enough recognition for the things I have\ndone.\n\n
\nI have a drinking problem that I have tried unsuccessfully to\nend.\n\n
\nLately, I get butterflies in my stomach and break out in cold\nsweats.\n\n
\nI have always wanted to stay in the background during social\nactivities.\n\n
\nDo you do most of your drinking at home?\n \n \n\n
\nI will often do things for no reason other than they might be\nfun.\n\n
\nI get very annoyed with people who never seem able to do things\nright.\n\n
\nIf my family puts pressure on me, I'm likely to feel angry and\nresist doing what they want.\n\n
\nI often feel I should be punished for the things I have done.\n\n
\nPeople make fun of me behind my back, talking about the way\nI act or look.\n\n
\nOther people seem more sure than I am of who they are and what\nthey want.\n\n
\nI tend to burst out in tears or in anger for unknown reasons.\n\n
\nI began to feel lonely and empty about a year or two ago.\n\n
\nI have a talent to be dramatic.\n\n
\nI have a hard time keeping my balance when walking.\n\n
\nDo you sneak drinks or hide bottles?\n \n \n\n
\nI enjoy intense competition.\n\n
\nWhen I run into a crisis, I quickly look for someone to help\nme.\n\n
\nI protect myself from trouble by never letting people know much\nabout me.\n\n
\nI feel weak and tired much of the time.\n\n
\nOther people get more angry about bothersome things than I do.\n\n
\nMy drug habits have often gotten me into a good deal of trouble\nIn the past.\n\n
\nLately, I find myself crying without any reason.\n\n
\nI think I'm a special person who deserves special attention from\nothers.\n\n
\nUnder no circumstances do I ever let myself be tricked by people\nwho say they need help.\n\n
\nOne sure way to make a peaceful world is by improving people's\nmorals.\n\n
\nHave you been drinking almost every day?\n \n \n\n
\nIn the past I've gotten involved sexually with many people who\ndidn't matter much to me.\n\n
\nI find it hard to sympathize with people who are always unsure\nabout things.\n\n
\nI am a very agreeable and submissive person.\n\n
\nMy own "bad temper" has been a big cause of my troubles.\n\n
\nI don't mind bullying others to get them to do what I want.\n\n
\nFor the past few years even minor things seem to depress me.\n\n
\nMy wish to get things done just perfectly often slows down\nmy work.\n\n
\nI'm so quiet and withdrawn, most people don't even know I\nexist.\n\n
\nI like to flirt with members of the opposite sex.\n\n
\nI am a quiet and fearful person.\n\n
\nDo you go "on the wagon" (not drink at all) after a period of drinking?\n \n \n\n
\nI'm a very erratic person, changing my mind and feelings\nall the time.\n\n
\nI feel very tense when I think of the day's happenings.\n\n
\nDrinking alcohol has never caused me any real problems in my\nwork.\n\n
\nLately, my strength seems to be draining out of me, even in the\nmorning.\n\n
\nI began to feel like a failure some years ago.\n\n
\nI strongly resent "big shots" who always think they can do\nthings better than I can.\n\n
\nI have always had a terrible fear that I will lose the love of\npeople I need very much.\n\n
\nI seem to go out of my way to let people take advantage of me.\n\n
\nLately, I have begun to feel like smashing things.\n\n
\nI have given serious thought recently to doing away with myself.\n\n
\nHave you had blackouts ("loss of memory" without passing out)\nas a result of drinking?\n \n \n\n\nI am always looking to make new friends and meet new people.\n\n
\nI keep very close track of my money so I am prepared if a need\ncomes up.\n\n
\nI was on the front cover of several magazines last year.\n\n
\nFew people like me.\n\n
\nIf someone criticized me for making a mistake, I would quickly\npoint out some of that person's mistakes.\n\n
\nSome people say I enjoy suffering.\n\n
\nI often let my angry feelings out and then feel terribly guilty\nabout it.\n\n
\nLately, I feel jumpy and under terrible strain, but I don't know\nwhy.\n\n
\nI very often lose my ability to feel any sensations in parts\nof my body.\n\n
\nI believe there are people who use telepathy to influence my\nlife.\n\n
\nHas your marriage or similar relationship broken up\nbecause of your drinking?\n \n \n\n
\nTaking so-called illegal drugs may be unwise, but in the past I\nfound I needed them.\n\n
\nI feel tired all the time.\n\n
\nI can't seem to sleep, and wake up just as tired as when I went\nto bed.\n\n
\nI've done a number of stupid things on impulse that ended up\ncausing me great trouble.\n\n
\nI never forgive an insult or forget an embarrassment that\nsomeone caused me.\n\n
\nWe should respect earlier generations and not think we know\nbetter than they.\n\n
\nI feel terribly depressed and sad much of the time now.\n\n
\nI am the sort of person that others take advantage of.\n\n
\nI always try hard to please others, even when I dislike them.\n\n
\nSerious thoughts of suicide have occurred to me for many years.\n\n
\nAs a result of drinking, have you seen things that were not there?\n \n \n\n
\nI quickly figure out how people are trying to cause me trouble.\n\n
\nI've always had less interest in sex than most people do.\n\n
\nI can't understand it, but I seem to enjoy hurting persons I\nlove.\n\n
\nA long time ago, I decided it's best to have little to do with\npeople.\n\n
\nI am ready to fight to the death before I'd let anybody take\naway my self-determination.\n\n
\nSince I was a child, I have had to watch out for people who were\ntrying to cheat me.\n\n
\nWhen things get boring, I like to stir up some excitement.\n\n
\nI have an alcohol problem that has made difficulties for me\nand my family.\n\n
\nIf a person wants something done that calls for real patience,\nthey should ask me.\n\n
\nI am probably the most creative thinker among the people I know.\n\n
\nWhat number comes next in the following series? 2 5 3 6\n\n
\nHave you had "shakes" when sobering up (hands tremble, shake inside, etc.)\nas a result of drinking?\n \n \n\n
\nI have not seen a car in the last ten years.\n\n
\nI don't see anything wrong with using people to get what I\nwant.\n\n
\nPunishment never stopped me from doing what I wanted.\n\n
\nThere are many times, when for no reason, I feel very cheerful\nand full of excitement.\n\n
\nI ran away from home as a teenager at least once.\n\n
\nI very often say things quickly that I regret having said.\n\n
\nIn recent weeks I feel worn out for no special reason.\n\n
\nFor some time now I've been feeling very guilty because I\ncan't do things right anymore.\n\n
\nIdeas keep turning over and over in my mind and they won't\ngo away.\n\n
\nI've become quite discouraged and sad about life in the past\nyear or two.\n\n
\nHave you developed swelling or puffiness in your hands, feet,\nor other parts of the body?\n \n \n\n
\nMany people have been spying into my private life for years.\n\n
\nI don't know why, but I sometimes say cruel things just to\nmake others unhappy.\n\n
\nI hate or fear most people.\n\n
\nI speak out my opinions about things no matter what others may\nthink.\n\n
\nWhen someone in authority insists that I do something, I'm\nlikely to put it off or do it poorly on purpose.\n\n
\nMy habit of abusing drugs has caused me to miss work in the\npast.\n\n
\nI am always willing to give in to others to avoid disagreements.\n\n
\nI am often cross and grouchy.\n\n
\nI just don't have the strength to fight back anymore.\n\n
\nLately, I have to think things over and over again for no\ngood reason.\n\n
\nWhen drinking, how much beer do you drink per day?\n \n \n\n
\nI often think that I don't deserve the good things that happen\nto me.\n\n
\nI use my charm to get the attention of other people.\n\n
\nWhen I'm alone, I often feel the strong presence of someone\nnearby who can't be seen.\n\n
\nI feel pretty aimless and don't know where I am going in\nlife.\n\n
\nLately, I have been sweating a great deal and feel very tense.\n\n
\nSometimes I feel like I must do something to hurt myself or\nsomeone else.\n\n
\nI have been unfairly punished by the law for crimes I never\ncommitted.\n\n
\nI've become very jumpy in the past few weeks.\n\n
\nI keep having strange thoughts that I wish I could get rid of.\n\n
\nI have a great deal of trouble trying to control an impulse to\ndrink to excess.\n\n
\nDo you avoid talking to others about your drinking?\n \n \n\n
\nMost people think that I am a worthless nothing.\n\n
\nI can get very excited sexually when fighting or arguing\nwith a loved one.\n\n
\nI have succeeded over the years in keeping my drinking of\nalcohol to a minimum.\n\n
\nI have always "tested" people to find out how much they can be\ntrusted.\n\n
\nEven when I am awake, I don't seem to notice people who are near\nme.\n\n
\nIt is very easy for me to make many friends.\n\n
\nI always make sure that my work is well planned and\norganized.\n\n
\nI very often hear things so well that it bothers me.\n\n
\nMy moods seem to change a great deal from one day to the next.\n\n
\nI don't blame anyone who takes advantage of someone who allows\nIt.\n\n
\nHave you turned to religion to help you with your drinking problem?\n \n \n\n
\nI've changed jobs more than three times in the past couple of\nyears.\n\n
\nI have many ideas that are ahead of the times.\n\n
\nFor some time now I have been feeling sad and blue and can't\nseem to snap out of it.\n\n
\nI think it is always best to seek help in what I do.\n\n
\nI often get angry with people who do things slowly.\n\n
\nI really get annoyed with people who expect me to do what I\ndon't want to do.\n\n
\nIn the last few years, I have felt so guilty that I may do\nsomething terrible to myself.\n\n
\nI never sit on the sidelines when I am at a party.\n\n
\nPeople tell me that I am a very proper and moral person.\n\n
\nI sometimes get confused and feel upset when people are kind to me.\n\n
\nHave others "pushed" you to take treatment for a drinking problem?\n \n \n\n
\nMy use of so-called illegal drugs has led to family arguments.\n\n
\nI am very ill-at-ease with members of the opposite sex.\n\n
\nThere are members of my family who say I'm selfish and think\nonly of myself.\n\n
\nI don't mind that people are not interested in me.\n\n
\nFrankly, I lie quite often to get out of trouble.\n\n
\nPeople can easily change my ideas, even if I thought my mind was\nmade up.\n\n
\nOthers have tried to do me in, but I have the will power\nto overcome them.\n\n
\nMy parents often told me that I was no good.\n\n
\nI often make people angry by bossing them\n\n
\nI have great respect for those in authority over me.\n\n
\nIs drinking a problem for you at this time?\n \n \n\n
\nI have almost no close ties with other people.\n\n
\nPeople have said in the past that I became too interested\nand too excited about too many things.\n\n
\nI have flown across the Atlantic thirty times in the last year.\n\n
\nI believe in the saying, "early to bed and early to rise..."\n\n
\nI deserve the suffering I've gone through in life.\n\n
\nMy feelings toward important people in my life often swing from\nloving them to hating them.\n\n
\nMy parents always disagreed with each other.\n\n
\nOn occasion I have had as many as ten or more drinks without\nbecoming drunk.\n\n
\nIn social groups I am almost always very self-conscious and\ntense.\n\n
\nI think highly of rules because they are a good guide to follow.\n\n
\nDoes drinking help you to overcome shyness?\n \n \n\n
\nEver since I was a child, I have been losing touch with the real\nworld.\n\n
\nI rarely feel anything strongly.\n\n
\nI used to be really restless, traveling around from place to\nplace with no idea of where I would end up.\n\n
\nI can't stand people who are late for appointments.\n\n
\nSneaky people often try to get the credit for things I have done\nor thought of.\n\n
\nI get very irritated if someone demands that I do things his\nway rather than my own.\n\n
\nI have the ability to be successful in almost anything I do.\n\n
\nLately, I have gone all to pieces.\n\n
\nI seem to encourage the people I love to hurt me.\n\n
\nThere has never been any hair on either my head or my body.\n\n
\nDo your ideas come more freely when you are drinking?\n \n \n\n
\nWhen I am with others I like to be the center of attention.\n\n
\nPeople who I admired greatly at first have often become real\ndisappointments to me later.\n\n
\nI'm the kind of person who can walk up to anyone and tell him or\nher off.\n\n
\nI prefer to be with people who will be protective of me.\n\n
\nI've had many periods in my life when I was so cheerful and\nused up so much energy that I fell into a low mood.\n\n
\nI have had difficulties in the past stopping myself from over-\nusing drugs or alcohol.\n\n
\nLately, my strength seems to be draining out of me, even in the morning.\n\n
\nI think highly of rules because they are a good guide to follow.\n\n
\nI enjoy doing so many different things that I can't make up my mind what\nto do first.\n\n
\nI feel weak and tired much of the time.\n\n
\nDo you drink to relieve tension and stress?\n \n \n\n
\nI know I'm a superior person, so I don't care what people think.\n\n
\nPeople have never given me enough recognition for the things I've done.\n\n
\nIf my family puts pressure on me, I'm likely to feel angry and resist\ndoing what they want.\n\n
\nPeople make fun of me behind my back, talking about the way I act or look.\n\n
\nI often criticize people strongly if they annoy me.\n\n
\nWhat few feelings I seem to have I rarely show to the outside world.\n\n
\nI have a hard time keeping my balance when walking.\n\n
\nI show my feelings easily and quickly.\n\n
\nMy drug habits have often gotten me into a good deal of trouble in the past.\n\n
\nSometimes I can be pretty rough and mean in my relations with my family.\n\n
\nAn equinox is:\n\n
\nHave you used alcohol to relieve cramps?\n \n \n\n
\nThings that are going well today won't last very long.\n\n
\nI am a very agreeable and submissive person.\n\n
\nAs a teenager, I got into lots of trouble because of bad school behavior.\n\n
\nI'm afraid to get really close to another person because it may end up\nwith my being ridiculed or shamed.\n\n
\nI seem to choose friends who end up mistreating me.\n\n
\nI've had sad thoughts much of my life since I was a child.\n\n
\nI like to flirt with members of the opposite sex.\n\n
\nI'm a very erratic person, changing my mind and feelings all the time.\n\n
\nDrinking alcohol has never caused me any real problems in my work.\n\n
\nI began to feel like a failure some years ago.\n\n
\nDo you do most of your drinking at bars?\n \n \n\n
\nI feel guilty much of the time for no reason that I know.\n\n
\nOther people envy my abilities.\n\n
\nWhen I have a choice, I prefer to do things alone.\n\n
\nI think it's necessary to place strict controls on the behavior of members\nof my family.\n\n
\nPeople usually think of me as a reserved and serious-minded person.\n\n
\nLately, I have begun to feel like smashing things.\n\n
\nI think I'm a special person who deserves special attention from others.\n\n
\nI am always looking to make new friends and meet new people.\n\n
\nIf someone criticized me for making a mistake, I would quickly point\nout some of that person's mistakes.\n\n
\nLately, I have gone all to pieces.\n\n
\nDo you drink in a bar by yourself?\n \n \n\n
\nI often give up doing things because I'm afraid I won't do them well.\n\n
\nI often let my angry feelings out and then feel terribly guilty about it.\n\n
\nI very often lose my ability to feel any sensations in parts of my body.\n\n
\nI do what I want without worrying about its effect on others.\n\n
\nTaking so-called illegal drugs may be unwise, but in the past I found I\nneeded them.\n\n
\nI guess I'm a fearful and inhibited person.\n\n
\nI've done a number of stupid things on impulse that ended up causing\nme great trouble.\n\n
\nI never forgive an insult or forget an embarrassment that someone\ncaused me.\n\n
\nI often feel sad or tense right after something good has happened to me.\n\n
\nI feel terribly depressed and sad much of the time now.\n\n
\nDo you usually have a bottle by your bedside?\n \n \n\n
\nI always try hard to please others, even when I dislike them.\n\n
\nI've always had less interest in sex than most people do.\n\n
\nI tend to always blame myself when things go wrong.\n\n
\nA long time ago, I decided it's best to have little to do with people.\n\n
\nSince I was a child, I have always had to watch out for people who were\ntrying to cheat me.\n\n
\nI strongly resent "big shots who always think they can do better\nthan I can.\n\n
\nWhen things get boring, I like to stir up some excitement.\n\n
\nI have an alcohol problem that has made difficulties for me and my family.\n\n
\nPunishment never stopped me from doing what I wanted.\n\n
\nThere are many times, when for no reason, I feel very cheerful and full of\nexcitement.\n\n
\nDo you drink mainly on weekends, holidays, or days off?\n \n \n\n
\nIn recent weeks I feel worn out for no special reason.\n\n
\nFor some time now I've been feeling very guilty because I can't do things\nright anymore.\n\n
\nI think I am a very sociable and outgoing person.\n\n
\nI've become very jumpy in the last few weeks.\n\n
\nI keep very close track of my money so I am prepared if a need comes up.\n\n
\nI just haven't had the luck in life that others have had.\n\n
\nIdeas keep turning over and over in my mind and they won't go away.\n\n
\nI've become quite discouraged and sad about my life in the past year or two.\n\n
\nMany people have been spying into my private life for years.\n\n
\nI don't know why, but sometimes I say cruel things just to make\nothers unhappy.\n\n
\nDo you drink heavily or get drunk on weekends, but not during the week?\n \n \n\n
\nI flew across the Atlantic thirty times last year.\n\n
\nMy habit of abusing drugs has caused me to miss work in the past.\n\n
\nI have many ideas that are ahead of the times.\n\n
\nLately, I have to think things over and over again for no good reason.\n\n
\nI avoid most social situations because I expect people to criticize or\nreject me.\n\n
\nI often think that I don't deserve the good things that happen to me.\n\n
\nWhen I'm alone, I often feel the strong presence of someone nearby who\ncan't be seen.\n\n
\nI feel pretty aimless and don't know where I'm going in life.\n\n
\nI often allow others to make important decisions for me.\n\n
\nI can't seem to sleep, and wake up just as tired as when I went to bed.\n\n
\nHow much did you drink the last time you drank?\n \n \n\n
\nLately, I've been sweating a great deal and feel very tense.\n\n
\nI keep having strange thoughts that I wish I could get rid of.\n\n
\nI have a great deal of trouble trying to control an impulse to drink\nto excess.\n\n
\nEven when I'm awake, I don't seem to notice people who are near me.\n\n
\nI am often cross and grouchy.\n\n
\nIt is very easy for me to make many friends.\n\n
\nI'm ashamed of some of the abuses I suffered when I was young.\n\n
\nI always make sure that my work is well planned and organized.\n\n
\nMy moods seem to change a great deal from one day to the next.\n\n
\nI'm too unsure of myself to risk trying something new.\n\n
\nHave you been detained or jailed for public drunkenness?\n \n \n\n
\nI don't blame anyone who takes advantage of someone who allows it.\n\n
\nFor some time now I've been feelings sad and blue and can't seem to snap\nout of it.\n\n
\nI often get angry with people who do things slowly.\n\n
\nI never sit on the sidelines when I'm at a party.\n\n
\nI watch my family closely so I'll know who can and who can't be trusted.\n\n
\nI sometimes get confused and feel upset when people are kind to me.\n\n
\nMy use of so-called illegal drugs has led to family arguments.\n\n
\nI'm alone most of the time and I prefer it that way.\n\n
\nThere are members of my family who say I'm selfish and think only of myself.\n\n
\nPeople can easily change my ideas, even if I thought my mind was made up.\n\n
\nAs a result of drinking, have you heard "things" that were not there?\n \n \n\n
\nI often make people angry by bossing them.\n\n
\nPeople have said in the past that I became too interested and too excited\nabout too many things.\n\n
\nI believe in saying, "early to bed and early to rise..."\n\n
\nMy feelings toward important people in my life often swing from loving\nthem to hating them.\n\n
\nIn social groups I am almost always very self-conscious and tense.\n\n
\nI guess I'm no different from my parents in becoming somewhat of\nan alcoholic.\n\n
\nI guess I don't take many of my family responsibilities as seriously as\nI should.\n\n
\nEver since I was a child, I have been losing touch with the real world.\n\n
\nSneaky people often try to get the credit for things I have done or\nthought of.\n\n
\nI can't experience much pleasure because I don't feel I deserve it.\n\n
\nDo you often have hangovers on Sunday or Monday mornings?\n \n \n\n
\nI have little desire for close friendships.\n\n
\nI've had many periods in my life when I was so cheerful and used up so\nmuch energy that I fell into a low mood.\n\n
\nI have completely lost my appetite and have trouble sleeping most nights.\n\n
\nI worry a great deal about being left alone and having to take care\nof myself.\n\n
\nThe memory of a very upsetting experience in my past keeps coming back to\nhaunt my thoughts.\n\n
\nI was on the front cover of several magazines last year.\n\n
\nI seem to have lost interest in most things that I used to find\npleasurable, such as sex.\n\n
\nI have been downhearted and sad much of my life since I was quite young.\n\n
\nI've gotten into trouble with the law a couple of times.\n\n
\nA good way to avoid mistakes is to have a routine for doing things.\n\n
\nIf a man drove 3 miles due north, then turned right\nand drove 2 miles and then turned right again and drove 3 miles,\nhow many miles would he be from where he started?\n\n
\nHave you experienced numbness or tingling in your hands (fingers)\nor feet (toes) that continued for a day or more?\n \n \n\n
\nOther people often blame me for things I didn't do.\n\n
\nI have had to be really rough with some people to keep them in line.\n\n
\nPeople think I sometimes talk about strange or different things than\nthey do.\n\n
\nThere have been times when I couldn't get through the day without some\nstreet drugs.\n\n
\nPeople are trying to make me believe that I'm crazy.\n\n
\nI'll do something desperate to prevent a person I love from abandoning me.\n\n
\nI go on eating binges a couple of times a week.\n\n
\nI seem to make a mess of good opportunities that come my way.\n\n
\nI've always had a hard time stopping myself from feeling blue and unhappy.\n\n
\nWhen I'm alone and away from home, I often begin to feel tense and panicky.\n\n
\nWhen drinking, how much wine do you drink per day?\n \n \n\n
\nPeople sometimes get annoyed with me because they say I talk too much or\ntoo fast for them.\n\n
\nMost successful people today have been either lucky of dishonest.\n\n
\nI won't get involved with people unless I'm sure they'll like me.\n\n
\nI feel deeply depressed for no reason I can figure out.\n\n
\nYears later I still have nightmares about an event that was a real threat\nto my life.\n\n
\nI don't have the energy to concentrate on my everyday responsibilities\nanymore.\n\n
\nDrinking alcohol helps when I'm feeling down.\n\n
\nI hate to think about some of the ways I was abused as a child.\n\n
\nEven in good times, I've always been afraid that things would soon go bad.\n\n
\nI sometimes feel crazy-like or unreal when things start to go badly in\nmy life.\n\n
\nAre you worried that your drinking is occurring at times other than the\ntimes you are accustomed to drinking?\n \n \n\n
\nBeing alone, without the help of someone close to depend on, really\nfrightens me.\n\n
\nI know I've spent more money than I should buying illegal drugs.\n\n
\nI always see to it that my work is finished before taking time out for\nleisure activities.\n\n
\nI can tell that people are talking about me when I pass them by.\n\n
\nI'm very good at making up excuses when I get into trouble.\n\n
\nI believe I'm being plotted against.\n\n
\nI feel that most people think poorly of me.\n\n
\nI frequently feel there's nothing inside me, like I'm empty and hollow.\n\n
\nI sometimes force myself to vomit after eating.\n\n
\nI guess I go out of my way to encourage people to admire the things I say\nor do.\n\n
\nDo you take tranquilizer pills to settle you down or to calm yourself?\n \n \n\n
\nI spend my life worrying over one thing or another.\n\n
\nI always wonder what the real reason is when someone is acting especially\nnice to me.\n\n
\nThere are certain thoughts that keep coming back again and again in my mind.\n\n
\nFew things in life give me pleasure.\n\n
\nI feel shaky and have difficulty falling asleep because painful memories\nof a past event keep running through my mind.\n\n
\nLooking ahead as each day begins makes me feel terribly depressed.\n\n
\nI've never been able to shake the feeling that I'm worthless to others.\n\n
\nI have a drinking problem that I've tried unsuccessfully to end.\n\n
\nSomeone has been trying to control my mind.\n\n
\nI have tried to commit suicide.\n\n
\nWould you like assistance with a drinking problem at this time?\n \n \n\n
\nI'm willing to starve myself to be even thinner than I am.\n\n
\nI don't understand why some people smile at me.\n\n
\nI have not seen a car in the last ten years.\n\n
\nI get very tense with people I don't know well because they may want to\nharm me.\n\n
\nSomeone would have to be pretty exceptional to understand my special\nabilities.\n\n
\nMy current life is still upset by flashbacks of something terrible that\nhappened to me.\n\n
\nI seem to create situations with others in which I get hurt or feel\nrejected.\n\n
\nI often get lost in my thoughts and forget what's going on around me.\n\n
\nPeople say I'm a thin person, but I feel that my thighs and backside are\nmuch too big.\n\n
\nThere are terrible events from my past that come back repeatedly to haunt\nmy thoughts and dreams.\n\n
\nAre you finding it difficult to live without alcohol?\n \n \n\n
\nOther than my family, I have no close friends.\n\n
\nI act quickly much of the time and don't think things through as I should.\n\n
\nI take great care to keep my life a private matter so no one can take\nadvantage of me.\n\n
\nI very often hear things so well that it bothers me.\n\n
\nI'm always willing to give in to others in a disagreement because I fear\ntheir anger or rejection.\n\n
\nI repeat certain behaviors again and again, sometimes to reduce my anxiety\nand sometimes to stop something bad from happening.\n\n
\nI have given serious thought recently to doing away with myself.\n\n
\nPeople tell me that I'm a very proper and moral person.\n\n
\nI still feel terrified when I think of a traumatic experience I had\nyears ago.\n\n
\nAlthough I'm afraid to make friendships, I wish I had more than I do.\n\n
\nDoes drinking help you get along with other people?\n \n \n\n
\nThere are people who are supposed to be my friends who would like to do\nme harm.\n\n
\nIf I get sick, it is my own behavior which determines how soon\nI get well again.\n\n
\nNo matter what I do, if I am going to get sick, I will get sick.\n\n
\nHaving regular contact with my physician is the best way\nfor me to avoid illness.\n\n
\nMost things that affect my health happen to me by accident.\n\n
\nWhenever I don't feel well, I should consult a medically\ntrained professional.\n\n
\nI am in control of my health.\n\n
\nMy family has a lot to do with my becoming sick or staying healthy.\n\n
\nWhen I get sick I am to blame.\n\n
\nLuck plays a big part in determining how soon I will recover\nfrom an illness.\n\n
\nDoes drinking help you feel that you can reach higher goals?\n \n \n\n
\nHealth professionals control my health.\n\n
\nMy good health is largely a matter of good fortune.\n\n
\nThe main thing which affects my health is what I myself do.\n\n
\nIf I take care of myself, I can avoid illness.\n\n
\nWhen I recover from an illness, it's usually because other\npeople (for example, doctors, nurses, family, friends) have\nbeen taking good care of me.\n\n
\nNo matter what I do, I'm likely to get sick.\n\n
\nIf it's meant to be, I will stay healthy.\n\n
\nIf I take the right actions, I can stay healthy.\n\n
\nRegarding my health, I can only do what my doctor tells me to do.\n\n
\nIf I become sick, I have the power to make myself well again.\n\n
\nDo you drink to let down?\n \n \n\n
\nOften I feel that no matter what I do, if I am going to get sick,\nI will get sick.\n\n
\nIf I see an excellent doctor regularly, I am less likely\nto have health problems.\n\n
\nIt seems that my health is greatly influenced by accidental\nhappenings.\n\n
\nI can only maintain my health by consulting health professionals.\n\n
\nI am directly responsible for my health.\n\n
\nOther people play a big part in whether I stay healthy or\nbecome sick.\n\n
\nWhatever goes wrong with my health is my own fault.\n\n
\nWhen I am sick, I just have to let nature run its course.\n\n
\nHealth professionals keep me healthy.\n\n
\nWhen I stay healthy, I'm just plain lucky.\n\n
\nHave you used alcohol to help you sleep?\n \n \n\n
\nMy physical well-being depends on how well I take care of myself.\n\n
\nWhen I feel ill, I know it is because I have not been taking\ncare of myself properly.\n\n
\nThe type of care I receive from other people is what is\nresponsible for how well I recover from an illness.\n\n
\nEven when I take care of myself, it's easy to get sick.\n\n
\nWhen I become ill, it's a matter of fate.\n\n
\nI can pretty much stay healthy by taking good care of myself.\n\n
\nFollowing doctor's orders to the letter is the best way\nfor me to stay healthy.\n\n
\nIf I get sick, it is my own behavior which determines how soon\nI get well again.\n\n
\nNo matter what I do, if I am going to get sick, I will get sick.\n\n
\nHaving regular contact with my physician is the best way\nfor me to avoid illness.\n\n
\nWhat number comes next in the following series? 23 30 38 47\n\n
\nDo you go to parties where there is drinking?\n \n \n\n
\nMost things that affect my health happen to me by accident.\n\n
\nWhenever I don't feel well, I should consult a medically\ntrained professional.\n\n
\nI am in control of my health.\n\n
\nMy family has a lot to do with my becoming sick or staying healthy.\n\n
\nWhen I get sick I am to blame.\n\n
\nLuck plays a big part in determining how soon I will recover\nfrom an illness.\n\n
\nHealth professionals control my health.\n\n
\nMy good health is largely a matter of good fortune.\n\n
\nThe main thing which affects my health is what I myself do.\n\n
\nIf I take care of myself, I can avoid illness.\n\n
\nWhen drinking with others, do you keep to yourself?\n \n \n\n
\nWhen I recover from an illness, it's usually because other\npeople (for example, doctors, nurses, family, friends) have\nbeen taking good care of me.\n\n
\nNo matter what I do, I'm likely to get sick.\n\n
\nIf it's meant to be, I will stay healthy.\n\n
\nIf I take the right actions, I can stay healthy.\n\n
\nRegarding my health, I can only do what my doctor tells me to do.\n\n
\nIf I become sick, I have the power to make myself well again.\n\n
\nOften I feel that no matter what I do, if I am going to get sick,\nI will get sick.\n\n
\nIf I see an excellent doctor regularly, I am less likely\nto have health problems.\n\n
\nIt seems that my health is greatly influenced by accidental\nhappenings.\n\n
\nI can only maintain my health by consulting health professionals.\n\n
\nDo you drink throughout the day?\n \n \n\n
\nI am directly responsible for my health.\n\n
\nOther people play a big part in whether I stay healthy or\nbecome sick.\n\n
\nWhatever goes wrong with my health is my own fault.\n\n
\nWhen I am sick, I just have to let nature run its course.\n\n
\nHealth professionals keep me healthy.\n\n
\nWhen I stay healthy, I'm just plain lucky.\n\n
\nMy physical well-being depends on how well I take care of myself.\n\n
\nWhen I feel ill, I know it is because I have not been taking\ncare of myself properly.\n\n
\nThe type of care I receive from other people is what is\nresponsible for how well I recover from an illness.\n\n
\nEven when I take care of myself, it's easy to get sick.\n\n
\nUsually how much time is there between your periods of\ndrinking--time when you don't drink at all?\n \n \n\n
\nWhen I become ill, it's a matter of fate.\n\n
\nI can pretty much stay healthy by taking good care of myself.\n\n
\nFollowing doctor's orders to the letter is the best way\nfor me to stay healthy.\n\n
\nI have always been able to overcome the problems I've had.\n\n
\nLately, life has been going along as usual, with no special things happening.\n\n
\nWhen I was a young child, my parents felt very proud of me.\n\n
\nI have almost never been sick.\n\n
\nI have friends who will listen to any problems I have.\n\n
\nI like to be the one in authority to take charge of things.\n\n
\nIf I were very sick, I'm sure that everything would work out well.\n\n
\nDo you alternate between periods of heavy continuous use of\nalcohol and periods of little or no use?\n \n \n\n
\nI always take the medicine a doctor tells me to even if I don't think it is working.\n\n
\nI am very pleased with all the things I have done up to now.\n\n
\nI almost never feel pressure in the work I do.\n\n
\nI get very frightened when I think of being all alone in the world.\n\n
\nI am ready to attack anyone who tries to say terrible things about me.\n\n
\nI have a feeling that things in my life just go from bad to worse.\n\n
\nAll my life I have to "blow up" every now and then.\n\n
\nThis year I was successful at something that was very Important to me.\n\n
\nI am in better health than most of my friends.\n\n
\nA quiet hobby is more fun for me than a party.\n\n
\nHave you passed out as a result of drinking?\n \n \n\n
\nMost people wouldn't care much if I were very sick.\n\n
\nI often say things that I regret having said.\n\n
\nI have lots of plans of what I'd like to be doing ten years from now.\n\n
\nI have a lot of faith that doctors can cure any sickness.\n\n
\nPeople can influence me quite easily.\n\n
\nI often find time to take it easy and do nothing.\n\n
\nEven in difficult times, I always try to be cheerful.\n\n
\nI don't mind that other people are not interested in my friendship.\n\n
\nI've had serious money problems this past year.\n\n
\nI almost always have medical problems.\n\n
\nAre you presently living alone as a result of drinking?\n \n \n\n
\nI often feel that others do not want to be friendly to me.\n\n
\nIf I became ill, I wouldn't have much help from my family.\n\n
\nIn many ways I feel very superior to most people.\n\n
\nIf I ever got a serious illness, I think it would be the end of me.\n\n
\nNo matter what, seeing a doctor can make me feel better.\n\n
\nSo little of what I have done has been appreciated by others.\n\n
\nKeeping to a time schedule is not important to me.\n\n
\nI've done most things in my life very well.\n\n
\nWhen I think about the past, I remember mostly the good things.\n\n
\nI make nasty remarks to people if they deserve it.\n\n
\nHave you had weird and frightening sensations when drinking?\n \n \n\n
\nI have had more than my share of troubles in the past year.\n\n
\nIt is good to have a regular way of doing things to avoid mistakes.\n\n
\nMany people have been spying into my private life for years.\n\n
\nI almost never worry about my health.\n\n
\nIf I thought I had a serious sickness, I would quickly talk it over with my family.\n\n
\nThere are always a number of reasons why most problems can't be solved.\n\n
\nI look forward to the future with lots of hope.\n\n
\nI do my best to get along with others by being pleasant and agreeable.\n\n
\nAll doctors care about is my money, not me.\n\n
\nI get upset when things I don't expect happen to me.\n\n
\nDo you get physically sick (vomit, stomach cramps, etc.) as\na result of drinking?\n \n \n\n
\nI often get angry with people who do things slowly.\n\n
\nI don't depend much on other people for friendship.\n\n
\nI feel pretty upset about most things in my life.\n\n
\nIt is very difficult for me to stop feelings from coming out.\n\n
\nMy family has had really bad problems in the past year.\n\n
\nI can stand a lot of pain.\n\n
\nI like to flirt a lot.\n\n
\nIn time of trouble there are several friends that I can depend on.\n\n
\nMost people can be trusted to be kind and thoughtful.\n\n
\nEven if I were very sick, I'd keep fighting and never give up.\n\n
\nIn times when you have had little or nothing to drink, have you\nnoticed that you were unsteady on your feet, having difficulty\nkeeping your balance?\n \n \n\n
\nI sometimes feel I am in this world all alone.\n\n
\nI feel that the doctors I have seen are not interested In my problems.\n\n
\nI am a dramatic and showy sort of person.\n\n
\nI can't stand people who are late for appointments.\n\n
\nI do my best to stop anyone from trying to boss me.\n\n
\nI often think about unhappy things that have happened to me.\n\n
\nI often do things for no reason other than it might be fun.\n\n
\nDuring the past year, someone close to me has been very ill.\n\n
\nI guess I'm a complainer who expects the worst to happen.\n\n
\nIt is not unusual to feel lonely and unwanted.\n\n
\nAffront means the same as:\n\n
\nDo you drink in the morning to relieve a hangover?\n \n \n\n
\nI worry a lot about my health.\n\n
\nLots of people would care about me if I became very sick.\n\n
\nI would much rather follow someone than be the leader.\n\n
\nIf I had a very serious sickness, I think I would fall apart mentally.\n\n
\nTo get ahead in this world I'm willing to push people who get In my way.\n\n
\nDoctors have always been helpful to me.\n\n
\nI find it hard to feel sorry for people who are always worried about things.\n\n
\nI seem to fit in right away with any group of people I meet.\n\n
\nI like being in a crowd just to be with lots of people.\n\n
\nMost of my problems just go on and on.\n\n
\nAre you afraid your drinking is getting worse?\n \n \n\n
\nI guess I depend too much on others to be helpful to me.\n\n
\nI moved during the past year.\n\n
\nI have always felt some kind of problem between me and the opposite sex.\n\n
\nI get frightened when I think I have a medical problem.\n\n
\nPunishment never stopped me from doing whatever I wanted.\n\n
\nI would have lots of visitors if I were in the hospital.\n\n
\nAmong the most important things a person can have are a strong will and the drive to get ahead.\n\n
\nI would never let a serious sickness stop me from working toward the future.\n\n
\nI often feel so angry that I want to throw and break things.\n\n
\nI dislike going to doctors, and do so only after trying everything myself.\n\n
\nDo you take medicine to help you sleep at night\n(such as sleeping pills or sedatives)?\n \n \n\n
\nI really hate to have my work pile up.\n\n
\nI find it hard to take my mind off my work even when I'm supposed to be relaxing.\n\n
\nI have not seen a car in the last ten years.\n\n
\nI very often think I am not wanted by others in a group.\n\n
\nEven when things seem to be going well, I expect that they'll soon get worse.\n\n
\nI would rather be direct with people than avoid telling them something they don't like.\n\n
\nMany important things have happened in my life this past year.\n\n
\nWhat this country really needs are more serious and devoted citizens.\n\n
\nAt no time in my life have I had any hair on my head or my body.\n\n
\nNUMBER OF QUESTIONS=150 QUESTION NUMBER1=1633\n\n
\nWhat is the maximum length of time you would be willing to stay in a\ntreatment program if you could solve your drinking problem permanently?\n \n \n\n
\nEver since I was a child I have been losing touch with the real world.\n\n
\nI cannot depend on my family when I need them.\n\n
\nI like to tell others about the things I have done well.\n\n
\nI'd rather be dead than have a very serious sickness.\n\n
\nI usually let other people have their own way.\n\n
\nI usually won't take any medicines, even if a doctor tells me to.\n\n
\nI wish the people around me would move faster and get more things done.\n\n
\nI often feel that there is nothing I can do to make my life easier.\n\n
\nI have very few close personal ties with others.\n\n
\nThis past year has been one of the most difficult ones in my life.\n\n
\nDoes your drinking interfere with fulfilling responsibilities\nto yourself or others?\n \n \n\n
\nIf I thought I were getting sick, I would quickly call a doctor.\n\n
\nI have a strong desire to win any game I play with others.\n\n
\nNobody really cares about my state of health.\n\n
\nI have faith that human nature is good.\n\n
\nI haven't thought much about what I'll be doing a year from now.\n\n
\nAll my life I have had the feeling that I have done something terribly wrong or evil.\n\n
\nWhen someone hurts me, I try to forget it.\n\n
\nHospitals are frightening and lonely places to be in.\n\n
\nMy work makes me tense almost all the time.\n\n
\nI have flown across the Atlantic 30 times last year.\n\n
\nDoes drinking help you to relax socially?\n \n \n\n
\nIn this world you either push or get shoved.\n\n
\nIf I were young again, I would do things very differently.\n\n
\nIt is very important that children learn to obey their elders.\n\n
\nI've had a lot of shocks and disappointments this past year.\n\n
\nRather than demand things, people can get what they want by being gentle and thoughtful.\n\n
\nI get very upset when I feel pain in any part of my body.\n\n
\nI can see more sides of a problem better than others can.\n\n
\nIf I were getting sick, I wouldn't waste my time telling anyone in my family.\n\n
\nI am more worried about finishing things that I start than most people.\n\n
\nFor me, the future looks like it will be full of trouble and problems.\n\n
\nDoes drinking help you work better?\n \n \n\n
\nI do my best not to hurt people's feelings.\n\n
\nI have never felt much life in me.\n\n
\nI would rather be in pain than take any medicines.\n\n
\nI often doubt whether people are really interested In what I am saying to them.\n\n
\nIt is very easy for me to relax and slow down.\n\n
\nI don't know what I want out of life.\n\n
\nLife has never gone well for me.\n\n
\nI've been touchy or tearful about everything most of my life.\n\n
\nI am very uneasy when I have to tell people what to do.\n\n
\nI am too rushed and busy to take the vacations I should.\n\n
\nDo you drink to forget?\n \n \n\n
\nThere has recently been an important change in my job.\n\n
\nI like to follow instructions and do what others expect of me.\n\n
\nI often think that I have a serious illness.\n\n
\nI am a quiet and cooperative person.\n\n
\nI'd be a pretty lonely person if I ever were hospitalized.\n\n
\nI become very excited or upset once a week or more.\n\n
\nI always try to do what is proper.\n\n
\nI don't think I would want to go on living if my body was marked up a lot in a serious operation.\n\n
\nI get so touchy that I can't talk about certain things.\n\n
\nFrom things I hear about them, I don't trust the people who work in hospitals.\n\n
\nHave you used alcohol to relieve neck or back pain?\n \n \n\n
\nI have a strong need to feel like an important person.\n\n
\nMy day is filled with pressures and responsibilities.\n\n
\nI like to arrange things down to the last detail.\n\n
\nBefore I entered the military I had more close friends than I have now.\n \n\n
\nI do not feel guilt over things that I did in the military.\n \n\n
\nIf someone pushes me too far, I am likely to become violent.\n \n\n
\nIf something happens that reminds me of the military, I become very\ndistressed and upset.\n \n\n
\nThe people who know me best are afraid of me.\n \n\n
\nI am able to get emotionally close to others.\n \n\n
\nI have nightmares of experiences in the military that really happened.\n \n\n
\nDo you usually drink with the same people?\n \n \n\n
\nWhen I think of some of the things that I did in the military, I wish\nI were dead.\n \n\n
\nIt seems as if I have no feelings.\n \n\n
\nLately, I have felt like killing myself.\n \n\n
\nI fall asleep, stay asleep and awaken only when the alarm goes off.\n \n\n
\nI wonder why I am still alive when others died in the military.\n \n\n
\nBeing in certain situations makes me feel as though I am back in\nthe military.\n \n\n
\nMy dreams at night are so real that I waken in a cold sweat and\nforce myself to stay awake.\n \n\n
\nI feel like I cannot go on.\n \n\n
\nI do not laugh or cry at the same things other people do.\n \n\n
\nI still enjoy doing many things that I used to enjoy.\n \n\n
\nDubious is to dubiousness as fleet is to:\n\n
\nDo you drink at home alone?\n \n \n\n
\nDaydreams are very real and frightening.\n \n\n
\nI have found it easy to keep a job since my separation from the\nmilitary.\n \n\n
\nI have trouble concentrating on tasks.\n \n\n
\nI have cried for no good reason.\n \n\n
\nI enjoy the company of others.\n \n\n
\nI am frightened by my urges.\n \n\n
\nI fall asleep easily at night.\n \n\n
\nUnexpected noises make me jump.\n \n\n
\nNo one understands how I feel, not even my family.\n \n\n
\nI am an easy-going, even-tempered person.\n \n\n
\nDo you carry a bottle with you or keep one close at hand?\n \n \n\n
\nI feel there are certain things that I did in the military that I\ncan never tell anyone, because no one would ever understand.\n \n\n
\nThere have been times when I used alcohol (or other drugs) to help me\nsleep or to make me forget about things that happened while I was in\nthe service.\n \n\n
\nI feel comfortable when I am in a crowd.\n \n\n
\nI lose my cool and explode over minor everyday things.\n \n\n
\nI am afraid to go to sleep at night.\n \n\n
\nI try to stay away from anything that will remind me of things\nwhich happened while I was in the military.\n \n\n
\nMy memory is as good as it ever was.\n \n\n
\nI have a hard time expressing my feelings, even to the people I care\nabout.\n\n
\nI like mechanics magazines.\n\n
\nI have a good appetite.\n\n
\nHow long do your periods of drinking usually continue?\n \n \n\n
\nI wake up fresh and rested most mornings.\n\n
\nI think I would like the work of a librarian.\n\n
\nI am easily awakened by noise.\n\n
\nMy father is a good man, or (if your father is dead) my\nfather was a good man.\n\n
\nI like to read newspaper articles on crime.\n\n
\nMy hands and feet are usually warm enough.\n\n
\nMy daily life is full of things that keep me interested.\n\n
\nI am about as able to work as I ever was.\n\n
\nThere seems to be a lump in my throat much of the time.\n\n
\nMy sex life is satisfactory.\n\n
\nHave you had periods when you would not let yourself drink?\n \n \n\n
\nPeople should try to understand their dreams and be guided by or\ntake warning from them.\n\n
\nI enjoy detective or mystery stories.\n\n
\nI work under a great deal of tension.\n\n
\nOnce in a while I think of things too bad to talk about.\n\n
\nI am sure I got a raw deal from life.\n\n
\nI am troubled by attacks of nausea and vomiting.\n\n
\nWhen I take a new job, I like to find out who it is important\nto be nice to.\n\n
\nI am very seldom troubled by constipation.\n\n
\nAt times I have very much wanted to leave home.\n\n
\nNo one seems to understand me.\n\n
\nWhen you drink, do you stumble about, stagger, and weave?\n \n \n\n
\nAt times I have fits of laughing and crying that I cannot control.\n\n
\nEvil spirits possess me at times.\n\n
\nI would like to be a singer.\n\n
\nI feel that it is certainly best to keep my mouth shut\nwhen I'm in trouble.\n\n
\nWhen people do me a wrong, I feel I should pay them back if\nI can, just for the principle of the thing.\n\n
\nI am bothered by an upset stomach several times\na week.\n\n
\nAt times I feel like swearing.\n\n
\nI have nightmares every few nights.\n\n
\nI find it hard to keep my mind on a task or job.\n\n
\nI have had very peculiar and strange experiences.\n\n
\nHave you received a ticket for driving under the influence of alcohol\nor driving while intoxicated?\n \n \n\n
\nI seldom worry about my health.\n\n
\nI have never been in trouble because of my sex behavior.\n\n
\nSometimes when I was young I stole things.\n\n
\nI have a cough most of the time.\n\n
\nAt times I feel like smashing things.\n\n
\nI have had periods of days, weeks, or months when I couldn't\ntake care of things because I couldn't "get going."\n\n
\nMy sleep is fitful and disturbed.\n\n
\nMuch of the time my head seems to hurt all over.\n\n
\nI do not always tell the truth.\n\n
\nIf people had not had it in for me, I would have been much\nmore successful.\n\n
\nAs a result of drinking, have you "felt things" crawling on you\nthat were not there (bugs, spiders, etc)?\n \n \n\n
\nMy judgment is better than it ever was.\n\n
\nOnce a week or oftener I suddenly feel hot all over, for no real\nreason.\n\n
\nI am in just as good physical health as most of my friends.\n\n
\nI prefer to pass by school friends, or people I know but have not\nseen for a long time, unless they speak to me first.\n\n
\nI am almost never bothered by pains over my heart or in my chest.\n\n
\nMost anytime I would rather sit and daydream than do anything else.\n\n
\nI am a very sociable person.\n\n
\nI have often had to take orders from someone who did not\nknow as much as I did.\n\n
\nI do not read every editorial in the newspaper every day.\n\n
\nI have not lived the right kind of life.\n\n
\nAs a result of drinking, have you felt your heart beating rapidly?\n \n \n\n
\nParts of my body often have feelings like burning, tingling,\ncrawling, or like "going to sleep."\n\n
\nMy family does not like the work I have chosen (or the work I intend\nto choose for my lifework).\n\n
\nI sometimes keep on at a thing until others lose their patience\nwith me.\n\n
\nI wish I could be as happy as others seem to be.\n\n
\nI hardly ever feel pain in the back of my neck.\n\n
\nI think a great many people exaggerate their misfortunes in\norder to gain the sympathy and help of others.\n\n
\nI am troubled by discomfort in the pit of my stomach every few days\nor oftener.\n\n
\nWhen I am with people, I am bothered by hearing very strange things.\n\n
\nI am an important person.\n\n
\nI have often wished I were a girl. (Or if you are a girl) I have\nnever been sorry that I am a girl.\n\n
\nHave you had severe difficulty in swallowing (food or liquid)?\n \n \n\n
\nMy feelings are not easily hurt.\n\n
\nI enjoy reading love stories.\n\n
\nMost of the time I feel blue.\n\n
\nIt would be better if almost all laws were thrown away.\n\n
\nI like poetry.\n\n
\nI sometimes tease animals.\n\n
\nI think I would like the kind of work a forest ranger does.\n\n
\nI am easily downed in an argument.\n\n
\nThese days I find it hard not to give up hope of amounting\nto something.\n\n
\nMy soul sometimes leaves my body.\n\n
\nWhen drinking, do you usually drink more than one kind of alcohol\n(for example, beer and hard liquor)?\n \n \n\n
\nI am certainly lacking in self-confidence.\n\n
\nI would like to be a florist.\n\n
\nI usually feel that life is worthwhile.\n\n
\nIt takes a lot of argument to convince most people of the truth.\n\n
\nOnce in a while I put off until tomorrow what I ought to do today.\n\n
\nI am liked by most people who know me.\n\n
\nI do not mind being made fun of.\n\n
\nI would like to be a nurse.\n\n
\nI think most people would lie to get ahead.\n\n
\nI do many things which I regret afterwards (I regret things\nmore than others seem to.\n\n
\n"what cannot be come at by care oft yields to cunning"\nmeans the same as:\n\n
\nIs the result of your drinking causing you to have noticeable fear?\n \n \n\n
\nI have very few quarrels with members of my family.\n\n
\nI was suspended from school one or more times for bad behavior.\n\n
\nAt times I have a strong urge to do something harmful or shocking.\n\n
\nI like to go to parties and other affairs where there is lots\nof loud fun.\n\n
\nI have met problems so full of possibilities that I have been unable\nto make up my mind about them.\n\n
\nI believe women ought to have as much sexual freedom as men.\n\n
\nMy hardest battles are with myself.\n\n
\nI love my father. (Or if your father is dead) I loved my father.\n\n
\nI have little or no trouble with my muscles twitching or jumping.\n\n
\nI don't seem to care what happens to me.\n\n
\nHave you ever had medical help to sober up?\n \n \n\n
\nSometimes when I am not feeling well I am irritable.\n\n
\nMuch of the time I feel as if I have done something wrong or evil.\n\n
\nI am happy most of the time.\n\n
\nI see things or animals or people around me that others do not see.\n\n
\nThere seems to be a fullness in my head or nose most of the time.\n\n
\nSome people are so bossy that I feel like doing the opposite of\nwhat they request, even though I know they are right.\n\n
\nSomeone has it in for me.\n\n
\nI have never done anything dangerous for the thrill of it.\n\n
\nOften I feel as if there is a tight band around my head.\n\n
\nI get angry sometimes.\n\n
\nHow much is it worth to you to correct your drinking problem permanently?\n \n \n\n
\nI enjoy a race or game more when I bet on it.\n\n
\nMost people are honest chiefly because they are afraid of\nbeing caught.\n\n
\nIn school I was sometimes sent to the principal for bad behavior.\n\n
\nMy speech is the same as always (not faster or slower, no slurring or\nhoarseness).\n\n
\nMy table manners are not quite as good at home as when I am\nout in company.\n\n
\nAnyone who is able and willing to work hard has a good chance of\nsucceeding.\n\n
\nI seem to be about as capable and smart as most others around me.\n\n
\nMost people will use somewhat unfair means to gain profit\nor an advantage rather than to lose it.\n\n
\nI have a great deal of stomach trouble.\n\n
\nI like dramatics.\n\n
\nDo you have a drinking problem?\n \n \n\n
\nI know who is responsible for most of my troubles.\n\n
\nSometimes I am so strongly attracted by the personal articles of others,\nsuch as shoes, gloves, etc., that I want to handle or steal them,\nthough I have no use for them.\n\n
\nThe sight of blood doesn't frighten me or make me sick.\n\n
\nOften I can't understand why I have been so irritable and grouchy.\n\n
\nI have never vomited blood or coughed up blood.\n\n
\nI do not worry about catching diseases.\n\n
\nI like collecting flowers or growing house plants.\n\n
\nI frequently find it necessary to stand up for what I think is right.\n\n
\nI have never indulged in any unusual sex practices.\n\n
\nAt times my thoughts have raced ahead faster than I could speak them.\n\n
\nDoes drinking help you to make friends?\n \n \n\n
\nIf I could get into a movie without paying and be sure than I was\nnot seen I would probably do it.\n\n
\nI often wonder what hidden reason another person may have\nfor doing something nice for me.\n\n
\nI believe that my home life is as pleasant as that of most people\nI know.\n\n
\nI believe in law enforcement.\n\n
\nCriticism or scolding hurts me terribly.\n\n
\nI like to cook.\n\n
\nMy conduct is largely controlled by the behavior of those around\nme.\n\n
\nI certainly feel useless at times.\n\n
\nWhen I was a child, I belonged to a group of friends that tried to\nbe loyal through all kinds of trouble.\n\n
\nI believe in a life hereafter.\n\n
\nAre you able to recall events in the past better when you are drinking?\n \n \n\n
\nI would like to be a soldier.\n\n
\nAt times I feel like picking a fist fight with someone.\n\n
\nI have often lost out on things because I couldn't make up my\nmind soon enough.\n\n
\nIt makes me impatient to have people ask my advice or otherwise interrupt\nme when I am working on something important.\n\n
\nI used to keep a diary.\n\n
\nI believe I am being plotted against.\n\n
\nI would rather win than lose in a game.\n\n
\nMost nights I go to sleep without thoughts or ideas bothering me.\n\n
\nDuring the past few years I have been well most of the time.\n\n
\nI have never had a fit or convulsion.\n\n
\nDo you frequently begin drinking because things pile up?\n \n \n\n
\nI am neither gaining or losing weight.\n\n
\nI believe I am being followed.\n\n
\nI feel that I have often been punished without cause.\n\n
\nI cry easily.\n\n
\nI cannot understand what I read as well as I use to.\n\n
\nI have never felt better in my life than I do now.\n\n
\nThe top of my head sometimes feels tender.\n\n
\nSometimes I feel as if I must injure either myself or someone else.\n\n
\nI resent having anyone trick me so cleverly that I have to\nadmit I was fooled.\n\n
\nI do not tire quickly.\n\n
\nHave you used alcohol to improve your sexual relations?\n \n \n\n
\nI like to know some important people because it makes me feel\nImportant.\n\n
\nI am afraid when I look down from a high place.\n\n
\nIt wouldn't make me nervous if any members of my family got in\ntrouble with the law.\n\n
\nI am never happy unless I am roaming or traveling around.\n\n
\nWhat others think of me does not bother me.\n\n
\nIt makes me uncomfortable to put on a stunt at a party even when others\nare doing the same sort of things.\n\n
\nI have never had a fainting spell.\n\n
\nI liked school.\n\n
\nI frequently have to fight against showing that I am bashful.\n\n
\nSomeone has been trying to poison me.\n\n
\nDo you do most of your drinking with friends and acquaintances?\n \n \n\n
\nI do not have a great fear of snakes.\n\n
\nI seldom or never have dizzy spells.\n\n
\nMy memory seems to be all right.\n\n
\nI am worried about sex.\n\n
\nI find it hard to make talk when I meet new people.\n\n
\nI have had periods in which I carried on activities without\nknowing later what I had been doing.\n\n
\nWhen I get bored I like to stir up some excitement.\n\n
\nI am afraid of losing my mind.\n\n
\nI am against giving money to beggars.\n\n
\nI frequently notice my hand shakes when I try to do something.\n\n
\nHave you stayed in a room by yourself and drunk?\n \n \n\n
\nI can read a long while without tiring my eyes.\n\n
\nI like to study and read about things that I am working at.\n\n
\nI feel weak all over much of the time.\n\n
\nI have very few headaches.\n\n
\nMy hands have not become clumsy or awkward.\n\n
\nSometimes, when embarrassed, I break out in a sweat which\nannoys me greatly.\n\n
\nI have had no difficulty in keeping my balance in walking.\n\n
\nThere is something wrong with my mind.\n\n
\nI do not have spells of hay fever or asthma.\n\n
\nI have had attacks in which I could not control my movements\nor speech but in which I knew what was going on around me.\n\n
\nFacial and Oral Movements\n \nLips and perioral area,\ne.g., puckering, pouting, smacking.\n \n\n
\nIf a factory can produce 20 units in 4 days at full employment,\nhow many units can be produced by three equivalent factories\nat half employment in 6 days, assuming that production is\nproportional to employment?\n\n
\nDo you drink during your workday?\n \n \n\n
\nI do not like everyone I know.\n\n
\nI daydream very little.\n\n
\nI wish I were not so shy.\n\n
\nI am not afraid to handle money.\n\n
\nIf I were a reporter I would very much like to report news of\nthe theater.\n\n
\nI enjoy many different kinds of play and recreation.\n\n
\nI like to flirt.\n\n
\nMy people treat me more like a child than a grown-up.\n\n
\nI would like to be a journalist.\n\n
\nMy mother is a good woman, or (if your mother is dead) my\nmother was a good woman.\n\n
\nDo you usually keep yourself somewhat intoxicated throughout each day?\n \n \n\n
\nIn walking I am very careful to step over sidewalk cracks.\n\n
\nI have never had any breaking out on my skin that has worried me.\n\n
\nThere is very little love and companionship in my family as\ncompared to other homes.\n\n
\nI frequently find myself worrying about something.\n\n
\nI think I would like the\nwork of a building contractor.\n\n
\nI often hear voices without knowing where they come from.\n\n
\nI like science.\n\n
\nIt is not hard for me to ask help from my\nfriends even though I cannot return the favor.\n\n
\nI very much like hunting.\n\n
\nMy parents often objected to the kind of people I went\naround with.\n\n
\nHave there been times when you "fell off the wagon"--started drinking\nwhen you had planned to not let yourself drink?\n \n \n\n
\nI gossip a little at times.\n\n
\nMy hearing is apparently as good as that of most people.\n\n
\nSome of my family have habits that bother and annoy me very much.\n\n
\nAt times I feel I can make up my mind with unusually great ease.\n\n
\nI would like to belong to several clubs.\n\n
\nI hardly ever notice my heart pounding and I am seldom short of breath.\n\n
\nI like to talk about sex.\n\n
\nI like to visit places where I have never been before.\n\n
\nI have been inspired to a program of life based on duty which\nI have since carefully followed.\n\n
\nI have at times stood in the way of people who were trying to\ndo something, not because it amounted to much but because of\nthe principle of the thing.\n\n
\nDo you gulp drinks (drink quickly)?\n \n \n\n
\nI get mad easily and then get over it soon.\n\n
\nI have been quite independent and free from family rule.\n\n
\nI brood a great deal.\n\n
\nSomeone has been trying to rob me.\n\n
\nMy relatives are nearly all in sympathy with me.\n\n
\nI have periods of such great restlessness that I cannot\nsit long in a chair.\n\n
\nI have been disappointed in love.\n\n
\nI never worry about my looks.\n\n
\nI dream frequently about things that are best kept to\nmyself.\n\n
\nChildren should be taught all the main facts of sex.\n\n
\nHave you missed work because of drinking during the past year?\n \n \n\n
\nI believe I am no more nervous than most others.\n\n
\nI have few or no pains.\n\n
\nMy way of doing things is apt to be misunderstood by others.\n\n
\nSometimes without any reason or even when things are going\nwrong I feel excitedly happy, "on top of the world."\n\n
\nI don't blame people for trying to grab everything they can get\nIn this world.\n\n
\nThere are persons who are trying to steal my thoughts and ideas.\n\n
\nI have had blank spells in which my activities were interrupted\nand I did not know what was going on around me.\n\n
\nI can be friendly with people who do things which I consider wrong.\n\n
\nI like to be with a crowd who play jokes on one another.\n\n
\nSometimes in elections I vote for people about whom I know\nvery little.\n\n
\nAs a result of drinking, have you ever had delirium tremens or\nDTs (seen, felt, or heard things not really there)?\n \n \n\n
\nI have difficulty in starting to do things.\n\n
\nI believe I am a condemned person.\n\n
\nI was a slow learner in school.\n\n
\nIf I were an artist I would like to draw flowers.\n\n
\nIt does not bother me that I am not better looking.\n\n
\nI sweat very easily even on cool days.\n\n
\nI am entirely self-confident.\n\n
\nAt times it has been impossible for me to keep from stealing or\nshoplifting something.\n\n
\nIt is safer to trust nobody.\n\n
\nOnce a week or oftener I become very excited.\n\n
\nAs a result of drinking, have you felt overly hot and sweaty (feverish)?\n \n \n\n
\nWhen in a group of people I have trouble thinking of the right\nthings to talk about.\n\n
\nSomething exciting will almost always pull me out of it when I\nam feeling low.\n\n
\nWhen I leave home I do not worry about whether the door is locked\nand the windows closed.\n\n
\nI believe my sins are unpardonable.\n\n
\nI have numbness in one or more places on my skin.\n\n
\nI do not blame a person for taking advantage of people who leave\nthemselves open to it.\n\n
\nMy eyesight is as good as it has been for years.\n\n
\nAt times I have been so entertained by the cleverness of some\ncriminals that I have hoped they would get away with it.\n\n
\nI have often felt that strangers were looking at me critically.\n\n
\nEverything tastes the same.\n\n
\nHave you ever coughed up blood or had blood in your stools?\n \n \n\n
\nI drink an unusually large amount of water every day.\n\n
\nMost people make friends because friends are likely to\nbe useful to them.\n\n
\nI do not often notice my ears ringing or buzzing.\n\n
\nOnce in a while I feel hate towards members of my family\nwhom I usually love.\n\n
\nIf I were a reporter I would very much like to report\nsporting news.\n\n
\nI can sleep during the day but not at night.\n\n
\nI am sure I am being talked about.\n\n
\nOnce in a while I laugh at a dirty joke.\n\n
\nI have very few fears compared to my friends.\n\n
\nIn a group of people I would not be embarrassed to be called\nupon to start a discussion or give an opinion about something\nI know well.\n\n
\nAfter an evening of heavy drinking, do you usually have something\nto eat before going to bed?\n \n \n\n
\nI am always disgusted with the law when a criminal is freed through\nthe arguments of a smart lawyer.\n\n
\nI have used alcohol excessively.\n\n
\nI am likely not to speak to people until they speak to me.\n\n
\nI have never been in trouble with the law.\n\n
\nI have periods in which I feel unusually cheerful without\nany special reason.\n\n
\nI wish I were not bothered by thoughts about sex.\n\n
\nIf several people find themselves in trouble, the best thing for\nthem to do is to agree upon a story and stick to it.\n\n
\nIt does not bother me particularly to see animals suffer.\n\n
\nI think that I feel more intensely than most people do.\n\n
\nThere never was a time in my life when I liked to play with dolls.\n\n
\nAre you usually depressed after a period of heavy drinking?\n \n \n\n
\nLife is a strain for me much of the time.\n\n
\nI am so touchy on some subjects than I can't talk about them.\n\n
\nIn school I found it very hard to talk in front of the class.\n\n
\nI love my mother, or (if your mother is dead) I loved my mother.\n\n
\nEven when I am with people I feel lonely much of the time.\n\n
\nI get all the sympathy I should.\n\n
\nI refuse to play some games because I am not good at them.\n\n
\nI seem to make friends about as quickly as others do.\n\n
\nI dislike having people around me.\n\n
\nI have been told that I walk during sleep.\n\n
\nSorrow is to misfortune as joy is to:\n\n
\nIn the last few months have you been attending AA (Alcoholics Anonymous)?\n \n \n\n
\nThe person who provides temptation by leaving valuable\nproperty unprotected is about as much to blame for its\ntheft as the one who steals it.\n\n
\nI think nearly anyone would tell a lie to keep out of trouble.\n\n
\nI am more sensitive than most other people.\n\n
\nMost people inwardly dislike putting themselves out to\nhelp other people.\n\n
\nMany of my dreams are about sex.\n\n
\nMy parents and family find more fault with me than they should.\n\n
\nI am easily embarrassed.\n\n
\nI worry over money and business.\n\n
\nI have never been in love with anyone.\n\n
\nThe things that some of my family have done have frightened me.\n\n
\nAre you eager to change your drinking behavior?\n \n \n\n
\nI almost never dream.\n\n
\nMy neck spots with red often.\n\n
\nI have never been paralyzed or had any unusual weakness in any of my\nmuscles.\n\n
\nSometimes my voice leaves me or changes even though I have\nno cold.\n\n
\nMy mother or father often made me obey even when I thought\nthat it was unreasonable.\n\n
\nPeculiar odors come to me at times.\n\n
\nI cannot keep my mind on one thing.\n\n
\nI have reason for feeling jealous of one or more members of\nmy family.\n\n
\nI feel anxiety about something or someone almost all the time.\n\n
\nI easily become impatient with people.\n\n
\nAre you able to regulate the times at which you drink?\n \n \n\n
\nMost of the time I wish I were dead.\n\n
\nSometimes I get so excited that I find it hard to get to sleep.\n\n
\nI have certainly had more than my share of things to worry about.\n\n
\nNo one cares much what happens to you.\n\n
\nAt times I hear so well it bothers me.\n\n
\nI forget right away what people say to me.\n\n
\nI usually have to stop and think before I act even in small\nmatters.\n\n
\nOften I cross the street in order not to meet someone I see.\n\n
\nI often feel as if things are not real.\n\n
\nThe only interesting part of newspapers is the comic strips.\n\n
\nWhen drinking, do you feel better able to express your ideas and opinions?\n \n \n\n
\nI have a habit of counting things that are not important such as\nbulbs on electric signs, and so forth.\n\n
\nI have no enemies who really wish to harm me.\n\n
\nI tend to be on my guard with people who are somewhat more friendly\nthan I had expected.\n\n
\nI have strange and peculiar thoughts.\n\n
\nI get anxious and upset when I have to make a short trip away from home.\n\n
\nI usually expect to succeed in things I do.\n\n
\nI hear strange things when I am alone.\n\n
\nI have been afraid of things or people that I knew could not hurt me.\n\n
\nI have no dread of going into a room by myself where other people\nhave already gathered and are talking.\n\n
\nI am afraid of using a knife or anything very sharp or pointed.\n\n
\nDoes drinking help you to become more creative?\n \n \n\n
\nSometimes I enjoy hurting people I love.\n\n
\nI can easily make other people afraid of me, and sometimes do\nfor the fun of it.\n\n
\nI have more trouble concentrating than others seem to have.\n\n
\nI have several times given up doing a thing because I thought\ntoo little of my ability.\n\n
\nBad words, often terrible words, come into my mind and I\ncannot get rid of them.\n\n
\nSometimes some unimportant thought will run through my mind and\nbother me for days.\n\n
\nAlmost everyday something happens to frighten me.\n\n
\nAt times I am all full of energy.\n\n
\nI am inclined to take things hard.\n\n
\nAt times I have enjoyed being hurt by someone I loved.\n\n
\nDo you start drinking to get over being depressed?\n \n \n\n
\nPeople say insulting and vulgar things about me.\n\n
\nI feel uneasy indoors.\n\n
\nI am not unusually self-conscious.\n\n
\nSomeone has control over my mind.\n\n
\nAt parties I am more likely to sit by myself or with just one other\nperson than to join in with the crowd.\n\n
\nPeople often disappoint me.\n\n
\nI have sometimes felt that difficulties were piling up so high\nthat I could not overcome them.\n\n
\nI love to go to dances.\n\n
\nAt periods my mind seems to work more slowly than usual.\n\n
\nWhile in trains, busses, etc., I often talk to strangers.\n\n
\nDo you drink to relieve headaches?\n \n \n\n
\nI enjoy children.\n\n
\nI enjoy gambling for small stakes.\n\n
\nIf given the chance I could do some things that would be of great\nbenefit to the world.\n\n
\nI have often met people who were supposed to be experts who were\nno better than I.\n\n
\nIt makes me feel like a failure when I hear of the success of\nsomeone I know well.\n\n
\nI often think, "I wish I were a child again."\n\n
\nI am never happier than when alone.\n\n
\nIf given the chance I would make a good leader of people.\n\n
\nI am embarrassed by dirty stories.\n\n
\nPeople generally demand more respect for their own rights than they\nare willing to allow for others.\n\n
\nDo you usually drink with a person of the opposite sex?\n \n \n\n
\nI enjoy social gatherings just to be with people.\n\n
\nI try to remember good stories to pass them on to other people.\n\n
\nAt one or more times in my life I felt that someone was making\nme do things by hypnotizing me.\n\n
\nI find it hard to set aside a task that I have undertaken, even\nfor a short time.\n\n
\nI am quite often not in on the gossip and talk of the group\nI belong to.\n\n
\nI have often found people jealous of my good ideas, just because\nthey had not thought of them first.\n\n
\nI enjoy the excitement of a crowd.\n\n
\nI do not mind meeting strangers.\n\n
\nSomeone has been trying to influence my mind.\n\n
\nI can remember "playing sick" to get out of something.\n\n
\nWhat is your usual style of drinking?\n \n \n\n
\nMy worries seem to disappear when I get into a crowd of\nlively friends.\n\n
\nI feel like giving up quickly when things go wrong.\n\n
\nI like to let people know where I stand on things.\n\n
\nI have had periods when I felt so full of pep that sleep did not\nseem necessary for days at a time.\n\n
\nWhenever possible I avoid being in a crowd.\n\n
\nI shrink from facing a crisis or difficulty.\n\n
\nI am apt to pass up something I want to do when others feel that\nIt isn't worth doing.\n\n
\nI like parties and socials.\n\n
\nI like mechanics magazines.\n\n
\nI have a good appetite.\n\n
\nDo you almost constantly think about drinking and alcohol?\n \n \n\n
\nI wake up fresh and rested most mornings.\n\n
\nI think I would like the work of a librarian.\n\n
\nI am easily awakened by noise.\n\n
\nMy father is a good man, or (if your father is dead) my father was a good man.\n\n
\nI like to read newspaper articles on crime.\n\n
\nMy hands and feet are usually warm enough.\n\n
\nMy daily life is full of things that keep me interested.\n\n
\nI am about as able to work as I ever was.\n\n
\nThere seems to be a lump in my throat much of the time.\n\n
\nMy sex life is satisfactory.\n\n
\nWhat number comes next in the following series? 1 5 3 7 5\n\n
\nWhat is the longest period that you have gone without alcohol in\nthe past 6 months?\n \n \n\n
\nPeople should try to understand their dreams and be guided by or take warning from them.\n\n
\nI enjoy detective or mystery stories.\n\n
\nI work under a great deal of tension.\n\n
\nOnce in a while I think of things too bad to talk about.\n\n
\nI am sure I get a raw deal from life.\n\n
\nI am troubled by attacks of nausea and vomiting.\n\n
\nWhen I take a new job, I like to find out who it is important to be nice to.\n\n
\nI am very seldom troubled by constipation.\n\n
\nAt times I have very much wanted to leave home.\n\n
\nNo one seems to understand me.\n\n
\nHas a holiday or special occasion started you into drinking for a\nperiod of several days or more?\n \n \n\n
\nAt times I have fits of laughing and crying that I cannot control.\n\n
\nEvil spirits possess me at times.\n\n
\nI would like to be a singer.\n\n
\nI feel that it is certainly best to keep my mouth shut when I'm in trouble.\n\n
\nWhen people do me a wrong, I feel I should pay them back if I can, just for the principle of the thing.\n\n
\nI am bothered by an upset stomach several times a week.\n\n
\nAt times I feel like swearing.\n\n
\nI have nightmares every few nights.\n\n
\nI find it hard to keep my mind on a task or job.\n\n
\nI have had very peculiar and strange experiences.\n\n
\nDo you lose control over what you do when you are drinking?\n \n \n\n
\nI seldom worry about my health.\n\n
\nI have never been in trouble because of my sex behavior.\n\n
\nSometimes when I was young I stole things.\n\n
\nI have a cough most of the time.\n\n
\nAt times I feel like smashing things.\n\n
\nI have had periods of days, weeks, or months when I couldn't take care of things because I couldn't "get going."\n\n
\nMy sleep is fitful and disturbed.\n\n
\nMuch of the time my head seems to hurt all over.\n\n
\nI do not always tell the truth.\n\n
\nIf people had not had it in for me, I would have been much more successful.\n\n
\nHave you ever taken the "geographic cure"--that is, moved from town to\ntown or place to place in order to stop drinking and make a new start?\n \n \n\n
\nMy judgment is better than it ever was.\n\n
\nOnce a week or oftener I suddenly feel hot all over, for no real reason.\n\n
\nI am in just as good physical health as most of my friends.\n\n
\nI prefer to pass by school friends, or people I know but have not seen for a long time, unless they speak to me first.\n\n
\nI am almost never bothered by pains over my heart or in my chest.\n\n
\nMost anytime I would rather sit and daydream than do anything else.\n\n
\nI am a very sociable person.\n\n
\nI have often had to take orders from someone who did not know as much as I did.\n\n
\nI do not read every editorial in the newspaper every day.\n\n
\nI have not lived the right kind of life.\n\n
\nAs a result of drinking, have you become confused about where you are,\nthe time, or the day of the week?\n \n \n\n
\nParts of my body often have feelings like burning, tingling, crawling, or like "going to sleep."\n\n
\nMy family does not like the work I have chosen (or the work I intend to choose for my lifework).\n\n
\nI sometimes keep on at a thing until others lose their patience with me.\n\n
\nI wish I could be as happy as others seem to be.\n\n
\nI hardly ever feel pain in the back of my neck.\n\n
\nI think a great many people exaggerate their misfortunes in order to gain the sympathy and help of others.\n\n
\nI am troubled by discomfort in the pit of my stomach every few days or oftener.\n\n
\nWhen I am with people, I am bothered by hearing very strange things.\n\n
\nI am an important person.\n\n
\nI have often wished I were a girl. (Or if you are a girl) I have never been sorry that I am a girl.\n\n
\nAs a result of drinking, have you had loose bowels, diarrhea,\nor similar physical problems?\n \n \n\n
\nMy feelings are not easily hurt.\n\n
\nI enjoy reading love stories.\n\n
\nMost of the time I feel blue.\n\n
\nIt would be better if almost all laws were thrown away.\n\n
\nI like poetry.\n\n
\nI sometimes tease animals.\n\n
\nI think I would like the kind of work a forest ranger does.\n\n
\nI am easily downed in an argument.\n\n
\nThese days I find it hard not to give up hope of amounting to something.\n\n
\nMy soul sometimes leaves my body.\n\n
\nTo your knowledge, do you have liver problems?\n \n \n\n
\nI am certainly lacking in self-confidence.\n\n
\nI would like to be a florist.\n\n
\nI usually feel that life is worthwhile.\n\n
\nIt takes a lot of argument to convince most people of the truth.\n\n
\nOnce in a while I put off until tomorrow what I ought to do today.\n\n
\nI am liked by most people who know me.\n\n
\nI do not mind being made fun of.\n\n
\nI would like to be a nurse.\n\n
\nI think most people would lie to get ahead.\n\n
\nI do many things which I regret afterwards (I regret things more than others seem to.).\n\n
\nAfter taking 1 or 2 drinks, can you usually stop?\n \n \n\n
\nI have very few quarrels with members of my family.\n\n
\nI was suspended from school one or more times for bad behavior.\n\n
\nAt times I have a strong urge to do something harmful or shocking.\n\n
\nI like to go to parties and other affairs where there is lots of loud fun.\n\n
\nI have met problems so full of possibilities that I have been unable to make up my mind about them.\n\n
\nI believe women ought to have as much sexual freedom as men.\n\n
\nMy hardest battles are with myself.\n\n
\nI love my father. (Or if your father is dead) I loved my father.\n\n
\nI have little or no trouble with my muscles twitching or jumping.\n\n
\nI don't seem to care what happens to me.\n\n
\nDo you have vague fears and anxieties after a period of drinking?\n \n \n\n
\nSometimes when I am not feeling well I am irritable.\n\n
\nMuch of the time I feel as if I have done something wrong or evil.\n\n
\nI am happy most of the time.\n\n
\nI see things or animals or people around me that others do not see.\n\n
\nThere seems to be a fullness in my head or nose most of the time.\n\n
\nSome people are so bossy that I feel like doing the opposite of what they request, even though I know they are right.\n\n
\nSomeone has it in for me.\n\n
\nI have never done anything dangerous for the thrill of it.\n\n
\nOften I feel as if there is a tight band around my head.\n\n
\nI get angry sometimes.\n\n
\nHow many times have you received help for your drinking problem?\n \n \n\n
\nI enjoy a race or game more when I bet on it.\n\n
\nMost people are honest chiefly because they are afraid of being caught.\n\n
\nIn school I was sometimes sent to the principal for bad behavior.\n\n
\nMy speech is the same as always (not faster or slower, no slurring or hoarseness).\n\n
\nMy table manners are not quite as good at home as when I am out in company.\n\n
\nAnyone who is able and willing to work hard has a good chance of succeeding.\n\n
\nI seem to be about as capable and smart as most others around me.\n\n
\nMost people will use somewhat unfair means to gain profit or an advantage rather than to lose it.\n\n
\nI have a great deal of stomach trouble.\n\n
\nI like dramatics.\n\n
\nIf 4 hogs eat 18 barrels of apples in two days, how many barrels\nof apples will 18 hogs eat in two days?\n\n
\nDo you believe that your drinking problem can be corrected?\n \n \n\n
\nI know who is responsible for most of my troubles.\n\n
\nSometimes I am so strongly attracted by the personal articles of others, such as shoes, gloves, etc., that I want to handle or steal them, though I have no use for them.\n\n
\nThe sight of blood doesn't frighten me or make me sick.\n\n
\nOften I can't understand why I have been so irritable and grouchy.\n\n
\nI have never vomited blood or coughed up blood.\n\n
\nI do not worry about catching diseases.\n\n
\nI like collecting flowers or growing house plants.\n\n
\nI frequently find it necessary to stand up for what I think is right.\n\n
\nI have never indulged in any unusual sex practices.\n\n
\nAt times my thoughts have raced ahead faster than I could speak them.\n\n
\nHow often have you been drunk in public in the past 6 months?\n \n \n\n
\nIf I could get into a movie without paying and be sure I was not seen I would probably do it.\n\n
\nI often wonder what hidden reason another person may have for doing something nice for me.\n\n
\nI believe that my home life is as pleasant as that of most people I know.\n\n
\nI believe in law enforcement.\n\n
\nCriticism or scolding hurts me terribly.\n\n
\nI like to cook.\n\n
\nMy conduct is largely controlled by the behavior of those around me.\n\n
\nI certainly feel useless at times.\n\n
\nWhen I was a child, I belonged to a group of friends that tried to be loyal through all kinds of trouble.\n\n
\nI believe in a life hereafter.\n\n
\nDo you go out to drink in order to meet people?\n \n \n\n
\nI would like to be a soldier.\n\n
\nAt times I feel like picking a fist fight with someone.\n\n
\nI have often lost out on things because I couldn't make up my mind soon enough.\n\n
\nIt makes me impatient to have people ask my advice or otherwise interrupt me when I am working on something important.\n\n
\nI used to keep a diary.\n\n
\nI believe I am being plotted against.\n\n
\nI would rather win than lose in a game.\n\n
\nMost nights I go to sleep without thoughts or ideas bothering me.\n\n
\nDuring the past few years I have been well most of the time.\n\n
\nI have never had a fit or convulsion.\n\n
\nAfter a few drinks are you better able to put your thoughts into words?\n \n \n\n
\nI am neither gaining nor losing weight.\n\n
\nI believe I am being followed.\n\n
\nI feel that I have often been punished without cause.\n\n
\nI cry easily.\n\n
\nI cannot understand what I read as well as I used to.\n\n
\nI have never felt better in my life than I do now.\n\n
\nThe top of my head sometimes feels tender.\n\n
\nSometimes I feel as if I must injure either myself or someone else.\n\n
\nI resent having anyone trick me so cleverly that I have to admit I was fooled.\n\n
\nI do not tire quickly.\n\n
\nDo you drink to get over being irritated or resentful?\n \n \n\n
\nI like to know some important people because it makes me feel Important.\n\n
\nI am afraid when I look down from a high place.\n\n
\nIt wouldn't make me nervous if any members of my family got into trouble with the law.\n\n
\nI am never happy unless I am roaming or traveling around.\n\n
\nWhat others think of me does not bother me.\n\n
\nIt makes me uncomfortable to put on a stunt at a party even when others are doing the same sort of things.\n\n
\nI have never had a fainting spell.\n\n
\nI liked school.\n\n
\nI frequently have to fight against showing that I am bashful.\n\n
\nSomeone has been trying to poison me.\n\n
\nDo you drink in order to have fun?\n \n \n\n
\nI do not have a great fear of snakes.\n\n
\nI seldom or never have dizzy spells.\n\n
\nMy memory seems to be all right.\n\n
\nI am worried about sex.\n\n
\nI find it hard to make talk when I meet new people.\n\n
\nI have had periods in which I carried on activities without knowing later what I had been doing.\n\n
\nWhen I get bored I like to stir up some excitement.\n\n
\nI am afraid of losing my mind.\n\n
\nI am against giving money to beggars.\n\n
\nI frequently notice my hand shakes when I try to do something.\n\n
\nIs drinking an important part of your getting together with people?\n \n \n\n
\nI can read a long while without tiring my eyes.\n\n
\nI like to study and read about things that I am working at.\n\n
\nI feel weak all over much of the time.\n\n
\nI have very few headaches.\n\n
\nMy hands have not become clumsy or awkward.\n\n
\nSometimes, when embarrassed, I break out in a sweat which annoys me greatly.\n\n
\nI have had no difficulty in keeping my balance in walking.\n\n
\nThere is something wrong with my mind.\n\n
\nI do not have spells of hay fever or asthma.\n\n
\nI have had attacks in which I could not control my movements or speech but in which I knew what was going on around me.\n\n
\nDo you drink alone?\n \n \n\n
\nI do not like everyone I know.\n\n
\nI daydream very little.\n\n
\nI wish I were not so shy.\n\n
\nI am not afraid to handle money.\n\n
\nIf I were a reporter I would very much like to report news of the theater.\n\n
\nI enjoy many different kinds of play and recreation.\n\n
\nI like to flirt.\n\n
\nMy people treat me more like a child than a grown-up.\n\n
\nI would like to be a journalist.\n\n
\nMy mother is a good woman, or (if your mother is dead) my mother was a good woman.\n\n
\nDo you get a craving to drink?\n \n \n\n
\nIn walking I am very careful to step over sidewalk cracks.\n\n
\nI have never had any breaking out on my skin that has worried me.\n\n
\nThere is very little love and companionship in my family as compared to other homes.\n\n
\nI frequently find myself worrying about something.\n\n
\nI think I would like the work of a building contractor.\n\n
\nI often hear voices without knowing where they come from.\n\n
\nI like science.\n\n
\nIt is not hard for me to ask help from my friends even though I cannot return the favor.\n\n
\nI very much like hunting.\n\n
\nMy parents often objected to the kind of people I went around with.\n\n
\nDuring the last few months, approximately how many days per\nmonth did you drink?\n \n \n\n
\nI gossip a little at times.\n\n
\nMy hearing is apparently as good as that of most people.\n\n
\nSome of my family have habits that bother and annoy me very much.\n\n
\nAt times I feel that I can make up my mind with unusually great ease.\n\n
\nI would like to belong to several clubs.\n\n
\nI hardly ever notice my heart pounding and I am seldom short of breath.\n\n
\nI like to talk about sex.\n\n
\nI like to visit places where I have never been before.\n\n
\nI have been inspired to a program of life based on duty which I have since carefully followed.\n\n
\nI have at times stood in the way of people who were trying to do something, not because it amounted to much but because of the principle of the thing.\n\n
\nA seal is a:\n\n
\nHave there been times when the urge to drink drove you from being sober\nInto a period of drinking for several days or more?\n \n \n\n
\nI get mad easily and then get over it soon.\n\n
\nI have been quite independent and free from family rule.\n\n
\nI brood a great deal.\n\n
\nSomeone has been trying to rob me.\n\n
\nMy relatives are nearly all in sympathy with me.\n\n
\nI have periods of such great restlessness that I cannot sit long in a chair.\n\n
\nI have been disappointed in love.\n\n
\nI never worry about my looks.\n\n
\nI dream frequently about things that are best kept to myself.\n\n
\nChildren should be taught all the main facts of sex.\n\n
\nWith respect to blackouts (loss of memory):\n \n \n\n
\nI believe I am no more nervous than most others.\n\n
\nI have few or no pains.\n\n
\nMy way of doing things is apt to be misunderstood by others.\n\n
\nSometimes without any reason or even when things are going wrong I feel excitedly happy, "on top of the world."\n\n
\nI don't blame people for trying to grab everything they can get In this world.\n\n
\nThere are persons who are trying to steal my thoughts and ideas.\n\n
\nI have had blank spells in which my activities were interrupted and I did not know what was going on around me.\n\n
\nI can be friendly with people who do things which I consider wrong.\n\n
\nI like to be with a crowd who play jokes on one another.\n\n
\nSometimes in elections I vote for people about whom I know very little.\n\n
\nHave you lost a job because of drinking?\n \n \n\n
\nI have difficulty in starting to do things.\n\n
\nI believe I am a condemned person.\n\n
\nI was a slow learner in school.\n\n
\nIf I were an artist I would like to draw flowers.\n\n
\nIt does not bother me that I am not better looking.\n\n
\nI sweat very easily even on cool days.\n\n
\nI am entirely self-confident.\n\n
\nAt times it has been impossible for me to keep from stealing or shoplifting something.\n\n
\nIt is safer to trust nobody.\n\n
\nOnce a week or oftener I become very excited.\n\n
\nAs a result of drinking, have you had a frightening dream when\nyou thought you were awake?\n \n \n\n
\nWhen in a group of people I have trouble thinking of the right things to talk about.\n\n
\nSomething exciting will almost always pull me out of it when I am feeling low.\n\n
\nWhen I leave home I do not worry about whether the door is locked and the windows closed.\n\n
\nI believe my sins are unpardonable.\n\n
\nI have numbness in one or more places on my skin.\n\n
\nI do not blame a person for taking advantage of people who leave themselves open to it.\n\n
\nMy eyesight is as good as it has been for years.\n\n
\nAt times I have been so entertained by the cleverness of some criminals that I have hoped they would get away with it.\n\n
\nI have often felt that strangers were looking at me critically.\n\n
\nEverything tastes the same.\n\n
\nAs a result of drinking, have you had the "inner shakes" (stomach\ntremors, jittery within)?\n \n \n\n
\nI drink an unusually large amount of water every day.\n\n
\nMost people make friends because friends are likely to be useful to them.\n\n
\nI do not often notice my ears ringing or buzzing.\n\n
\nOnce in a while I feel hate towards members of my family whom I usually love.\n\n
\nIf I were a reporter I would very much like to report sporting news.\n\n
\nI can sleep during the day but not at night.\n\n
\nI am sure I am being talked about.\n\n
\nOnce in a while I laugh at a dirty joke.\n\n
\nI have very few fears compared to my friends.\n\n
\nIn a group of people I would not be embarrassed to be called upon to start a discussion or give an opinion about something I know well.\n\n
\nHave you experienced memory difficulties such as completely forgetting\nan appointment made earlier in the day?\n \n \n\n
\nI am always disgusted with the law when a criminal is freed through the arguments of a smart lawyer.\n\n
\nI have used alcohol excessively.\n\n
\nI am likely not to speak to people until they speak to me.\n\n
\nI have never been in trouble with the law.\n\n
\nI have periods in which I feel unusually cheerful without any special reason.\n\n
\nI wish I were not bothered by thoughts about sex.\n\n
\nIf several people find themselves in trouble, the best thing for them to do is to agree upon a story and stick to it.\n\n
\nIt does not bother me particularly to see animals suffer.\n\n
\nI think that I feel more intensely than most people do.\n\n
\nThere never was a time in my life when I liked to play with dolls.\n\n
\nWhen drinking over a period of several days, do you:\n \n \n\n
\nLife is a strain for me much of the time.\n\n
\nI am so touchy on some subjects that I can't talk about them.\n\n
\nIn school I found it very hard to talk in front of the class.\n\n
\nI love my mother, or (if your mother is dead) I loved my mother.\n\n
\nEven when I am with people I feel lonely much of the time.\n\n
\nI get all the sympathy I should.\n\n
\nI refuse to play some games because I am not good at them.\n\n
\nI seem to make friends about as quickly as others do.\n\n
\nI dislike having people around me.\n\n
\nI have been told that I walk during sleep.\n\n
\nDo you make excuses or lie to cover up your drinking?\n \n \n\n
\nThe person who provides temptation by leaving valuable property unprotected is about as much to blame for its theft as the one who steals it.\n\n
\nI think nearly anyone would tell a lie to keep out of trouble.\n\n
\nI am more sensitive than most other people.\n\n
\nMost people inwardly dislike putting themselves out to help other people.\n\n
\nMany of my dreams are about sex.\n\n
\nMy parents and family find more fault with me than they should.\n\n
\nI am easily embarrassed.\n\n
\nI worry over money and business.\n\n
\nI have never been in love with anyone.\n\n
\nThe things that some of my family have done have frightened me.\n\n
\nHow many times have you entered a counseling or therapy program for\na drinking problem?\n \n \n\n
\nI almost never dream.\n\n
\nMy neck spots with red often.\n\n
\nI have never been paralyzed or had any unusual weakness of any of my muscles.\n\n
\nSometimes my voice leaves me or changes even though I have no cold.\n\n
\nMy mother or father often made me obey even when I thought that it was unreasonable.\n\n
\nPeculiar odors come to me at times.\n\n
\nI cannot keep my mind on one thing.\n\n
\nI have reason for feeling jealous of one or more members of my family.\n\n
\nI feel anxiety about something or someone almost all the time.\n\n
\nI easily become impatient with people.\n\n
\nDo you believe you are likely to accept the advice and suggestions\nof an alcohol counselor?\n \n \n\n
\nMost of the time I wish I were dead.\n\n
\nSometimes I become so excited that I find it hard to get to sleep.\n\n
\nI have certainly had more than my share of things to worry about.\n\n
\nNo one cares much what happens to you.\n\n
\nAt times I hear so well it bothers me.\n\n
\nI forget right away what people say to me.\n\n
\nI usually have to stop and think before I act even in small matters.\n\n
\nOften I cross the street in order not to meet someone I see.\n\n
\nI often feel as if things are not real.\n\n
\nThe only interesting part of newspapers is the comic strips.\n\n
\nWhat number comes next in the following series? 1 7 19 43\n\n
\nWhen drinking heavily, how much do you typically sleep during\na 24-hour period?\n \n \n\n
\nI have a habit of counting things that are not important such as bulbs on electric signs, and so forth.\n\n
\nI have no enemies who really wish to harm me.\n\n
\nI tend to be on my guard with people who are somewhat more friendly than I had expected.\n\n
\nI have strange and peculiar thoughts.\n\n
\nI get anxious and upset when I have to make a short trip away from home.\n\n
\nI usually expect to succeed in things I do.\n\n
\nI hear strange things when I am alone.\n\n
\nI have been afraid of things or people that I knew could not hurt me.\n\n
\nI have no dread of going into a room by myself where other people have already gathered and are talking.\n\n
\nI am afraid of using a knife or anything very sharp or pointed.\n\n
\nWhen you are drinking, are you better able to relate your feelings\nand thoughts to the opposite sex?\n \n \n\n
\nSometimes I enjoy hurting persons I love.\n\n
\nI can easily make other people afraid of me, and sometimes do for the fun of it.\n\n
\nI have more trouble concentrating than others seem to have.\n\n
\nI have several times given up doing a thing because I thought too little of my ability.\n\n
\nBad words, often terrible words, come into my mind and I cannot get rid of them.\n\n
\nSometimes some unimportant thought will run through my mind and bother me for days.\n\n
\nAlmost everyday something happens to frighten me.\n\n
\nAt times I am all full of energy.\n\n
\nI am inclined to take things hard.\n\n
\nAt times I have enjoyed being hurt by someone I loved.\n\n
\nDoes drinking help you think better?\n \n \n\n
\nPeople say insulting and vulgar things about me.\n\n
\nI feel uneasy indoors.\n\n
\nI am not unusually self-conscious.\n\n
\nSomeone has control over my mind.\n\n
\nAt parties I am more likely to sit by myself or with just one other person than to join in with the crowd.\n\n
\nPeople often disappoint me.\n\n
\nI have sometimes felt that difficulties were piling up so high that I could not overcome them.\n\n
\nI love to go to dances.\n\n
\nAt periods my mind seems to work more slowly than usual.\n\n
\nWhile in trains, busses, etc., I often talk to strangers.\n\n
\nDoes drinking help you deal with your worries?\n \n \n\n
\nI enjoy children.\n\n
\nI enjoy gambling for small stakes.\n\n
\nIf given the chance I could do some things that would be of great benefit to the world.\n\n
\nI have often met people who were supposed to be experts who were no better than I.\n\n
\nIt makes me feel like a failure when I hear of the success of someone I know well.\n\n
\nI often think, "I wish I were a child again."\n\n
\nI am never happier than when alone.\n\n
\nIf given the chance I would make a good leader of people.\n\n
\nI am embarrassed by dirty stories.\n\n
\nPeople generally demand more respect for their own rights than they are willing to allow for others.\n\n
\nDo you encourage other people (such as your wife, husband,\nfriends) to drink with you?\n \n \n\n
\nI enjoy social gatherings just to be with people.\n\n
\nI try to remember good stories to pass them on to other people.\n\n
\nAt one or more times in my life I felt that someone was making me do things by hypnotizing me.\n\n
\nI find it hard to set aside a task that I have undertaken, even for a short time.\n\n
\nI am quite often not in on the gossip and talk of the group I belong to.\n\n
\nI have often found people jealous of my good ideas, just because they had not thought of them first.\n\n
\nI enjoy the excitement of a crowd.\n\n
\nI do not mind meeting strangers.\n\n
\nSomeone has been trying to influence my mind.\n\n
\nI can remember "playing sick" to get out of something.\n\n
\nDoes your work put you in the position of being expected to drink?\n \n \n\n
\nMy worries seem to disappear when I get into a crowd of lively friends.\n\n
\nI feel like giving up quickly when things go wrong.\n\n
\nI like to let people know where I stand on things.\n\n
\nI have had periods when I felt so full of pep that sleep did not seem necessary for days at a time.\n\n
\nWhenever possible I avoid being in a crowd.\n\n
\nI shrink from facing a crisis or difficulty.\n\n
\nI am apt to pass up something I want to do when others feel that It isn't worth doing.\n\n
\nI like parties and socials.\n\n
\nI have often wished I were a member of the opposite sex.\n\n
\nI am not easily angered.\n\n
\nWhen you find yourself alone, do you drink?\n \n \n\n
\nI have done some bad things in the past that I never tell anybody about.\n\n
\nMost people will use somewhat unfair means to get ahead in life.\n\n
\nIt makes me nervous when people ask me personal questions.\n\n
\nI do not feel I can plan my own future.\n\n
\nI am not happy with myself the way I am.\n\n
\nI get angry when my friends or family give me advice on how to live my life.\n\n
\nI got many beatings when I was a child.\n\n
\nIt bothers me when people say nice things about me.\n\n
\nI don't like hearing other people give their opinions about life.\n\n
\nI often have serious disagreements with people who are close to me.\n\n
\nDo you plan ahead to make sure you have alcohol on hand?\n \n \n\n
\nWhen things get really bad, I know I can count on my family for help.\n\n
\nI liked playing "house" when I was a child.\n\n
\nI am not afraid of fire.\n\n
\nI have sometimes stayed away from another person because I feared doing or saying something that I might regret afterwards.\n\n
\nI can express my true feelings only when I drink.\n\n
\nI very seldom have spells of the blues.\n\n
\nI am often said to be hotheaded.\n\n
\nI wish I could get over worrying about things I have said that may have injured other people's feelings.\n\n
\nI feel unable to tell anyone all about myself.\n\n
\nLightning is one of my fears.\n\n
\nDo you drink in the morning, afternoon, and evening?\n \n \n\n
\nI like to keep people guessing what I'm going to do next.\n\n
\nMy plans have frequently seemed so full of difficulties that I have had to give them up.\n\n
\nI am afraid to be alone in the dark.\n\n
\nI have often felt bad about being misunderstood when trying to keep someone from making a mistake.\n\n
\nA windstorm terrifies me.\n\n
\nI frequently ask people for advice.\n\n
\nThe future is too uncertain for a person to make serious plans.\n\n
\nOften, even though everything is going fine for me, I feel that I don't care about anything.\n\n
\nI have no fear of water.\n\n
\nI often must sleep over a matter before I decide what to do.\n\n
\nHave you forced yourself to do without alcohol for several days or weeks?\n \n \n\n
\nPeople have often misunderstood my intentions when I was trying to put them right and be helpful.\n\n
\nI have no trouble swallowing.\n\n
\nI am usually calm and not easily upset.\n\n
\nI would certainly enjoy beating criminals at their own game.\n\n
\nI deserve severe punishment for my sins.\n\n
\nI am apt to take disappointments so keenly that I can't put them out of my mind.\n\n
\nIt bothers me to have someone watch me at work even though I know I can do it well.\n\n
\nI am often so annoyed when someone tries to get ahead of me in a line of people that I speak to that person about it.\n\n
\nAt times I think I am no good at all.\n\n
\nWhen I was young I often did not go to school even when I should have gone.\n\n
\nYou have a big box, within which are 3 smaller boxes, and inside\neach of them are 3 very small boxes. In all there are:\n\n
\nDo you tend to be physically harmful to other people when drinking?\n \n \n\n
\nOne or more members of my family are very nervous.\n\n
\nI have at times had to be rough with people who were rude or annoying.\n\n
\nI worry quite a bit over possible misfortunes.\n\n
\nI have strong political opinions.\n\n
\nI would like to be an auto racer.\n\n
\nIt is all right to get around the law if you don't actually break it.\n\n
\nThere are certain people whom I dislike so much that I am Inwardly pleased when they are catching it for something they have done.\n\n
\nIt makes me nervous to have to wait.\n\n
\nI am apt to pass up something I want to do because others feel that I am not going about it in the right way.\n\n
\nI was fond of excitement when I was young.\n\n
\nOver the last year, have you "called in sick" or been "half with it"\nat work because of drinking?\n \n \n\n
\nI am often inclined to go out of my way to win a point with someone who has opposed me.\n\n
\nI am bothered by people outside, on the streets, in stores, etc., watching me.\n\n
\nThe man who had most to do with me when I was a child (such as my father, stepfather, etc.) was very strict with me.\n\n
\nI used to like to play hopscotch and jump rope.\n\n
\nI have never seen a vision.\n\n
\nI have several times had a change of heart about my lifework.\n\n
\nExcept by doctor's orders I never take drugs or sleeping pills.\n\n
\nI am often sorry because I am so irritable and grouchy.\n\n
\nIn school my marks in classroom behavior were quite regularly bad.\n\n
\nI am fascinated by fire.\n\n
\nAs a result of drinking, have you become overly suspicious and\nmistrusting of others?\n \n \n\n
\nWhen I am cornered I tell that portion of the truth which is not likely to hurt me.\n\n
\nIf I was in trouble with several friends who were as guilty as I was, I would rather take the whole blame than give them away.\n\n
\nI am often afraid of the dark.\n\n
\nWhen a man is with a woman he is usually thinking about things related to her sex.\n\n
\nI am usually very direct with people I am trying to correct or improve.\n\n
\nI dread the thought of an earthquake.\n\n
\nI readily become one hundred percent sold on a good idea.\n\n
\nI usually work things out for myself rather than get someone to show me how.\n\n
\nI am afraid of finding myself in a closet or small closed space.\n\n
\nI must admit that I have at times been worried beyond reason over something that really did not matter.\n\n
\nAs a result of drinking, have you had the "chills," felt cold, or\nbroken out in the cold sweats?\n \n \n\n
\nI do not try to cover up my poor opinion or pity of people so that they won't know how I feel.\n\n
\nI am a high-strung person.\n\n
\nI have frequently worked under people who seem to have things arranged so that they get credit for good work but are able to pass off mistakes onto those under them.\n\n
\nI sometimes find it hard to stick up for my rights because I am so reserved.\n\n
\nDirt frightens or disgusts me.\n\n
\nI have a daydream life about which I do not tell other people.\n\n
\nSome of my family have quick tempers.\n\n
\nI cannot do anything well.\n\n
\nI often feel guilty because I pretend to feel more sorry about something than I really do.\n\n
\nI strongly defend my own opinions as a rule.\n\n
\nAs a result of drinking, have you lost your drive or ambition?\n \n \n\n
\nI have no fear of spiders.\n\n
\nThe future seems hopeless to me.\n\n
\nThe members of my family and my close relatives get along quite well.\n\n
\nI would like to wear expensive clothes.\n\n
\nPeople can pretty easily change my mind even when I have made a decision about something.\n\n
\nI am made nervous by certain animals.\n\n
\nI can stand as much pain as others can.\n\n
\nSeveral times I have been the last to give up trying to do a thing.\n\n
\nIt makes me angry to have people hurry me.\n\n
\nI am not afraid of mice.\n\n
\nHave you ever broken out in small sores as a result of drinking?\n \n \n\n
\nSeveral times a week I feel as if something dreadful is about to happen.\n\n
\nI feel tired a good deal of the time.\n\n
\nI like repairing a door latch.\n\n
\nSometimes I am sure that other people can tell what I am thinking.\n\n
\nI like to read about science.\n\n
\nI am afraid of being alone in a wide-open place.\n\n
\nI sometimes feel that I am about to go to pieces.\n\n
\nA large number of people are guilty of bad sexual conduct.\n\n
\nI have often been frightened in the middle of the night.\n\n
\nI am greatly bothered by forgetting where I put things.\n\n
\nDo you have guilt or remorse after a drunk?\n \n \n\n
\nThe one to whom I was most attached and whom I most admired as a child was a woman (mother, sister, aunt, or other woman).\n\n
\nI like adventure stories better than romantic stories.\n\n
\nOften I get confused and forget what I want to say.\n\n
\nI am very awkward and clumsy.\n\n
\nI really like playing rough sports (such as football or soccer).\n\n
\nI hate my whole family.\n\n
\nSome people think it's hard to get to know me.\n\n
\nI spend most of my spare time by myself.\n\n
\nWhen people do something that makes me angry, I let them know how I feel about it.\n\n
\nI usually have a hard time deciding what to do.\n\n
\nHave you been hospitalized for alcohol problems?\n \n \n\n
\nPeople do not find me attractive.\n\n
\nPeople are not very kind to me.\n\n
\nI often feel that I'm not as good as other people.\n\n
\nI am very stubborn.\n\n
\nI have enjoyed using marijuana.\n\n
\nMental illness is a sign of weakness.\n\n
\nI have a drug or alcohol problem.\n\n
\nGhosts or spirits can influence people for good or bad.\n\n
\nI feel helpless when I have to make some important decisions.\n\n
\nI always try to be pleasant even when others are upset or critical.\n\n
\nHave you ever considered getting help with problems which you currently\nhave, but put it off or changed your mind?\n \n \n\n
\nWhen I have a problem it helps to talk it over with someone.\n\n
\nMy main goals in life are within my reach.\n\n
\nI believe that people should keep personal problems to themselves.\n\n
\nI am not feeling much pressure or stress these days.\n\n
\nIt bothers me greatly to think of making changes in my life.\n\n
\nMy greatest problems are caused by the behavior of someone close to me.\n\n
\nI hate going to doctors even when I am sick.\n\n
\nAlthough I am not happy with my life, there is nothing I can do about it now.\n\n
\nTalking over problems and worries with someone is often more helpful than taking drugs or medicine.\n\n
\nI have some habits that are really harmful.\n\n
\nDo you turn to a less socially accepted life when drinking?\n \n \n\n
\nWhen problems need to be solved, I usually let other people take charge.\n\n
\nI recognize several faults in myself that I will not be able to change.\n\n
\nI am so sick of what I have to do every day that I just want to get out of it all.\n\n
\nI have recently considered killing myself.\n\n
\nI often become very irritable when people interrupt my work.\n\n
\nI often feel I can read other people's minds.\n\n
\nHaving to make important decisions makes me nervous.\n\n
\nOthers tell me I eat too fast.\n\n
\nOnce a week or more I get high or drunk.\n\n
\nI have had a tragic loss in my life that I know I'll never get over.\n\n
\nAnger is to violence as love is to:\n\n
\nDoes drinking help you to feel more confident in relating to others?\n \n \n\n
\nSometimes I get so angry and upset I don't know what comes over me.\n\n
\nWhen people ask me to do something I have a hard time saying no.\n\n
\nI am never happier than when I am by myself.\n\n
\nMy life is empty and meaningless.\n\n
\nI find it difficult to hold down a job.\n\n
\nI have made lots of bad mistakes in my life.\n\n
\nI get angry with myself for giving in to other people so much.\n\n
\nLately I have thought a lot about killing myself.\n\n
\nI like making decisions and assigning jobs to others.\n\n
\nEven without my family I know there will always be someone there to take care of me.\n\n
\nDoes alcohol enable you to better perform particular tasks?\n \n \n\n
\nAt movies, restaurants, or sporting events, I hate to have to stand In line.\n\n
\nNo one knows it but I have tried to kill myself.\n\n
\nEverything is going on too fast around me.\n\n
\nI know I am a burden to others.\n\n
\nAfter a bad day, I usually need a few drinks to relax.\n\n
\nMuch of the trouble I'm having is due to bad luck.\n\n
\nAt times I can't seem to stop talking.\n\n
\nSometimes I cut or injure myself on purpose without knowing why.\n\n
\nI work very long hours even though my job doesn't require this.\n\n
\nI usually feel better after a good cry.\n\n
\nWhen drinking, do you become obviously a different person?\n \n \n\n
\nI forget where I leave things.\n\n
\nIf I could live my life over again, I would not change much.\n\n
\nI get very irritable when people I depend on don't get their work done on time.\n\n
\nIf I get upset I'm sure to get a headache.\n\n
\nI like to drive a hard bargain.\n\n
\nMost men are unfaithful to their wives now and then.\n\n
\nLately I have lost my desire to work out my problems.\n\n
\nI have gotten angry and broken furniture or dishes when I was drinking.\n\n
\nI work best when I have a definite deadline.\n\n
\nI have become so angry with someone that I have felt as if I would explode.\n\n
\nAre you usually happier when you are drinking?\n \n \n\n
\nTerrible thoughts about my family come to me at times.\n\n
\nPeople tell me I have a problem with alcohol but I disagree.\n\n
\nI always have too little time to get things done.\n\n
\nMy thoughts these days turn more and more to death and the life hereafter.\n\n
\nI often keep and save things that I will probably never use.\n\n
\nI've been so angry at times that I've hurt someone in a physical fight.\n\n
\nIn everything I do lately I feel that I am being tested.\n\n
\nI have very little to do with my relatives now.\n\n
\nI sometimes seem to hear my thoughts being spoken out loud.\n\n
\nWhen I am sad, visiting with friends can always pull me out of it.\n\n
\nDo you show marked resentments when you drink?\n \n \n\n
\nMuch of what is happening to me now seems to have happened to me before.\n\n
\nWhen my life gets difficult, it makes me want to just give up.\n\n
\nI can't go into a dark room alone even in my own home.\n\n
\nI worry a great deal over money.\n\n
\nThe man should be the head of the family.\n\n
\nThe only place where I feel relaxed is in my own home.\n\n
\nThe people I work with are not sympathetic with my problems.\n\n
\nI am satisfied with the amount of money I make.\n\n
\nI usually have enough energy to do my work.\n\n
\nIt is hard for me to accept compliments.\n\n
\nDo you resent others talking about your drinking?\n \n \n\n
\nIn most marriages one or both partners are unhappy.\n\n
\nI almost never lose self-control.\n\n
\nIt takes a great deal of effort for me to remember what people tell me these days.\n\n
\nWhen I am sad or blue, it is my work that suffers.\n\n
\nMost married couples don't show much affection for each other.\n\n
\nI am not a worrier.\n\n
\nI really like most people I meet.\n\n
\nI have a very active imagination.\n\n
\nI tend to be cynical and skeptical of others' intentions.\n\n
\nI'm known for my prudence and common sense.\n\n
\nIf you have not had a drink for several hours, do you feel an urge\nto have one?\n \n \n\n
\nI often get angry at the way people treat me.\n\n
\nI shy away from crowds of people.\n\n
\nAesthetic and artistic concerns aren't very important to me.\n\n
\nI'm not crafty or sly.\n\n
\nI would rather keep my options open than plan everything in advance.\n\n
\nI rarely feel lonely or blue.\n\n
\nI am dominant, forceful, and assertive.\n\n
\nWithout strong emotions, life would be uninteresting to me.\n\n
\nSome people think I'm selfish and egotistical.\n\n
\nI try to perform all the tasks assigned to me conscientiously.\n\n
\nHow would you describe your drinking over the last few years?\n \n \n\n
\nIn dealing with other people, I always dread making a social blunder.\n\n
\nI have a leisurely style in work and play.\n\n
\nI'm pretty set in my ways.\n\n
\nI would rather cooperate with others than compete with them.\n\n
\nI am easy-going and lackadaisical.\n\n
\nI rarely overindulge in anything.\n\n
\nI often crave excitement.\n\n
\nI often enjoy playing with theories or abstract ideas.\n\n
\nI don't mind bragging about my talents and accomplishments.\n\n
\nI'm pretty good about pacing myself so as to get things done on time.\n\n
\nHave there been periods when you have stayed drunk for several days\nat a time and then cut back to lesser amounts or stopped completely?\n \n \n\n
\nI often feel helpless and want someone else to solve my problems.\n\n
\nI have never literally jumped for joy.\n\n
\nI believe letting students hear controversial speakers can only confuse and mislead them.\n\n
\nPolitical leaders need to be more aware of the human side of their policies.\n\n
\nOver the years I've done some pretty stupid things.\n\n
\nI am easily frightened.\n\n
\nI don't get much pleasure from chatting with people.\n\n
\nI try to keep all my thoughts directed along realistic lines and avoid flights of fancy.\n\n
\nI believe that most people are basically well-intentioned.\n\n
\nI don't take civic duties like voting very seriously.\n\n
\nHave you ever attempted suicide when drinking?\n \n \n\n
\nI'm an even-tempered person.\n\n
\nI like to have a lot of people around me.\n\n
\nI am sometimes completely absorbed in music I am listening to.\n\n
\nIf necessary, I am willing to manipulate people to get what I want.\n\n
\nI keep my belongings neat and clean.\n\n
\nSometimes I feel completely worthless.\n\n
\nI sometimes fail to assert myself as much as I should.\n\n
\nI rarely experience strong emotions.\n\n
\nI try to be courteous to everyone I meet.\n\n
\nSometimes I'm not as dependable or reliable as I should be.\n\n
\n"wise men learn by other men's mistakes, fools by their own"\nmeans the same as:\n\n
\nHave you felt psychologically or physically dependent on or\naddicted to alcohol?\n \n \n\n
\nI seldom feel self-conscious when I'm around people.\n\n
\nWhen I do things, I do them vigorously.\n\n
\nI think it's interesting to learn and develop new hobbies.\n\n
\nI can be sarcastic and cutting when I need to be.\n\n
\nI have a clear set of goals and work toward them in an orderly fashion.\n\n
\nI have trouble resisting my cravings.\n\n
\nI wouldn't enjoy vacationing in Las Vegas.\n\n
\nI find philosophical arguments boring.\n\n
\nI'd rather not talk about myself and my achievements.\n\n
\nI waste a lot of time before settling down to work.\n\n
\nDo you do things on the spur of the moment when drinking?\n \n \n\n
\nI feel I am capable of coping with most of my problems.\n\n
\nI have sometimes experienced intense joy or ecstasy.\n\n
\nI believe that laws and social policies should change to reflect the need of a changing world.\n\n
\nI'm hard-headed and tough-minded in my attitudes.\n\n
\nI think things through before coming to a decision.\n\n
\nI rarely feel fearful or anxious.\n\n
\nI'm known as a warm and friendly person.\n\n
\nI have an active fantasy life.\n\n
\nI believe that most people will take advantage of you if you let them.\n\n
\nI keep myself informed and usually make intelligent decisions.\n\n
\nAs a result of drinking, have you had severe headaches?\n \n \n\n
\nI am known as hot-blooded and quick tempered.\n\n
\nI usually prefer to do things alone.\n\n
\nWatching ballet or modern dance bores me.\n\n
\nI couldn't deceive anyone even if I wanted to.\n\n
\nI am not a very methodical person.\n\n
\nI am seldom sad or depressed.\n\n
\nI have often been a leader of groups I have belonged to.\n\n
\nHow I feel about things is important to me.\n\n
\nSome people think of me as cold and calculating.\n\n
\nI pay my debts promptly and in full.\n\n
\nWhen you drink at a bar or party in the evening, how many drinks do\nyou usually have before calling it a night?\n \n \n\n
\nAt times I have been so ashamed I just wanted to hide.\n\n
\nMy work is likely to be slow but steady.\n\n
\nOnce I find the right way to do something, I stick to it.\n\n
\nI hesitate to express my anger even when it's justified.\n\n
\nWhen I start a self-improvement program, I usually let it slide after a few days.\n\n
\nI have little difficulty resisting temptation.\n\n
\nI have sometimes done things just for "kicks" or "thrills."\n\n
\nI enjoy solving problems or puzzles.\n\n
\nI'm better than most people, and I know it.\n\n
\nI am a productive person who always gets the job done.\n\n
\nHave you ever had a "dry drunk" (act or feel like you are drunk when\nyou have had nothing to drink)?\n \n \n\n
\nWhen I'm under a great deal of stress, sometimes I feel like I'm going to pieces.\n\n
\nI am not a cheerful optimist.\n\n
\nI believe we should look to our religious authorities for decisions on moral issues.\n\n
\nWe can never do too much for the poor and elderly.\n\n
\nOccasionally I act first and think later.\n\n
\nI often feel tense and jittery.\n\n
\nMany people think of me as somewhat cold and distant.\n\n
\nI don't like to waste my time daydreaming.\n\n
\nI think most of the people I deal with are honest and trustworthy.\n\n
\nI often come into situations without being fully prepared.\n\n
\nHave you felt guilty or shameful because of drinking to excess?\n \n \n\n
\nI am not considered a touchy or temperamental person.\n\n
\nI really feel the need for other people if I am by myself for long.\n\n
\nI am intrigued by the patterns I find in art and nature.\n\n
\nBeing perfectly honest is a bad way to do business.\n\n
\nI like to keep everything in its place so I know just where it is.\n\n
\nI have sometimes experienced a deep sense of guilt or sinfulness.\n\n
\nIn meetings, I usually let others do the talking.\n\n
\nI seldom pay much attention to my feelings of the moment.\n\n
\nI generally try to be thoughtful and considerate.\n\n
\nSometimes I cheat when I play solitaire.\n\n
\nHave you seen a psychologist, psychiatrist, or alcohol counselor\nfor alcohol problems?\n \n \n\n
\nIt doesn't embarrass me too much if people ridicule and tease me.\n\n
\nI often feel as if I'm bursting with energy.\n\n
\nI often try new and foreign foods.\n\n
\nIf I don't like people, I let them know it.\n\n
\nI work hard to accomplish my goals.\n\n
\nWhen I am having my favorite foods, I tend to eat too much.\n\n
\nI tend to avoid movies that are shocking or scary.\n\n
\nI sometimes lose interest when people talk about very abstract, theoretical matters.\n\n
\nI try to be humble.\n\n
\nI have trouble making myself do what I should.\n\n
\nHave you drunk hair tonic, shaving lotion, canned heat, or\nanything like these?\n \n \n\n
\nI keep a cool head in emergencies.\n\n
\nSometimes I bubble with happiness.\n\n
\nI believe that the different ideas of right and wrong that people in other societies have may be valid for them.\n\n
\nI have no sympathy for panhandlers.\n\n
\nI always consider the consequences before I take action.\n\n
\nI'm seldom apprehensive about the future.\n\n
\nI really enjoy talking to people.\n\n
\nI enjoy concentrating on a fantasy or daydream and exploring all its possibilities, letting it grow and develop.\n\n
\nI'm suspicious when someone does something nice for me.\n\n
\nI pride myself on my sound judgment.\n\n
\nHave you been in a detoxification center to sober up?\n \n \n\n
\nI often get disgusted with people I have to deal with.\n\n
\nI prefer jobs that let me work alone without being bothered by other people.\n\n
\nPoetry has little or no effect on me.\n\n
\nI would hate to be thought of as a hypocrite.\n\n
\nI never seem to be able to get organized.\n\n
\nI tend to blame myself when anything goes wrong.\n\n
\nOther people often look to me to make decisions.\n\n
\nI experience a wide range of emotions or feelings.\n\n
\nI'm not known for my generosity.\n\n
\nWhen I make a commitment, I can always be counted on to follow through.\n\n
\nDoes drinking help you to become more talkative and open with people?\n \n \n\n
\nI often feel inferior to others.\n\n
\nI'm not as quick and lively as other people.\n\n
\nI prefer to spend my time in familiar surroundings.\n\n
\nWhen I've been insulted, I just try to forgive and forget.\n\n
\nI don't feel like I'm driven to get ahead.\n\n
\nI seldom give in to my impulses.\n\n
\nI like to be where the action is.\n\n
\nI enjoy working on "mind-twister"-type puzzles.\n\n
\nI have a very high opinion of myself.\n\n
\nOnce I start a project, I almost always finish it.\n\n
\nIf a stenographer can type at the rate of 60 words per minute,\nhow long will it take her to type 10 letters, 5 of which consist\nof 480 words each, and the other 5 of 600 words each?\n\n
\nDoes drinking help you to have fun and be happy?\n \n \n\n
\nIt's often hard for me to make up my mind.\n\n
\nI don't consider myself especially "light-hearted."\n\n
\nI believe that loyalty to one's ideals and principles is more important than "open-mindedness."\n\n
\nHuman need should always take priority over economic considerations.\n\n
\nI often do things on the spur of the moment.\n\n
\nI often worry about things that might go wrong.\n\n
\nI find it easy to smile and be outgoing with strangers.\n\n
\nIf I feel my mind starting to drift off into daydreams, I usually get busy and start concentrating on some work or activity instead.\n\n
\nMy first reaction is to trust people.\n\n
\nI don't seem to be completely successful at anything.\n\n
\nDoes drinking help you deal with recurring feelings of\ngrief (loss of a loved one)?\n \n \n\n
\nIt takes a lot to get me mad.\n\n
\nI'd rather vacation at a popular beach than an isolated cabin in the woods.\n\n
\nCertain kinds of music have an endless fascination for me.\n\n
\nSometimes I trick people into doing what I want.\n\n
\nI tend to be somewhat fastidious or exacting.\n\n
\nI have a low opinion of myself.\n\n
\nI would rather go my own way than be a leader of others.\n\n
\nI seldom notice the moods or feelings that different environments produce.\n\n
\nMost people I know like me.\n\n
\nI adhere strictly to my ethical principles.\n\n
\nHave you been drinking to handle disappointments in your life?\n \n \n\n
\nI feel comfortable in the presence of my bosses or other authorities.\n\n
\nI usually seem to be in a hurry.\n\n
\nSometimes I make changes around the house just to try something different.\n\n
\nIf someone starts a fight, I'm ready to fight back.\n\n
\nI strive to achieve all I can.\n\n
\nI sometimes eat myself sick.\n\n
\nI love the excitement of roller coasters.\n\n
\nI have little interest in speculating on the nature of the universe or the human condition.\n\n
\nI feel that I am no better than others, no matter what their condition.\n\n
\nWhen a project gets too difficult, I'm inclined to start a new one.\n\n
\nWhen you are drinking, are your moods about the same as when\nyou do not drink?\n \n \n\n
\nI can handle myself pretty well in a crisis.\n\n
\nI am a cheerful, high-spirited person.\n\n
\nI consider myself broad-minded and tolerant of other people's lifestyles.\n\n
\nI believe all human beings are worthy of respect.\n\n
\nI rarely make hasty decisions.\n\n
\nI have fewer fears than most people.\n\n
\nI have strong emotional attachments to my friends.\n\n
\nAs a child I rarely enjoyed games of make believe.\n\n
\nI tend to assume the best about people.\n\n
\nI'm a very competent person.\n\n
\nWhen drinking, are you often very sad (for example, cry a lot)?\n \n \n\n
\nAt times I have felt bitter and resentful.\n\n
\nSocial gatherings are usually boring to me.\n\n
\nSometimes when I am reading poetry or looking at a work of art, I feel a chill or wave of excitement.\n\n
\nAt times I bully or flatter people into doing what I want them to.\n\n
\nI'm not compulsive about cleaning.\n\n
\nSometimes things look pretty bleak and hopeless to me.\n\n
\nIn conversations, I tend to do most of the talking.\n\n
\nI find it easy to empathize--to feel myself what others are feeling.\n\n
\nI think of myself as a charitable person.\n\n
\nI try to do jobs carefully, so they won't have to be done again.\n\n
\nDo you drink to help you go to sleep at night?\n \n \n\n
\nIf I have said or done the wrong thing to someone, I can hardly bear to face them again.\n\n
\nMy life is fast-paced.\n\n
\nOn a vacation, I prefer going back to a tried and true spot.\n\n
\nI'm hard-headed and stubborn.\n\n
\nI strive for excellence in everything I do.\n\n
\nSometimes I do things on impulse that I later regret.\n\n
\nI'm attracted to bright colors and flashy styles.\n\n
\nI have a lot of intellectual curiosity.\n\n
\nI would rather praise others than be praised myself.\n\n
\nThere are so many little jobs that need to be done that I sometimes just Ignore them all.\n\n
\nDo you become critical or judgmental of people when drinking?\n \n \n\n
\nWhen everything seems to be going wrong, I can still make good decisions.\n\n
\nI rarely use words like "fantastic!" or "sensational!" to describe my experiences.\n\n
\nI think that if people don't know what they believe in by the time they're 25, there's something wrong with them.\n\n
\nI have sympathy for others less fortunate than me.\n\n
\nI plan ahead carefully when I go on a trip.\n\n
\nFrightening thoughts sometimes come into my head.\n\n
\nI take a personal interest in the people I work with.\n\n
\nI would have difficulty just letting my mind wander without control or guidance.\n\n
\nI have a good deal of faith in human nature.\n\n
\nI am efficient and effective at my work.\n\n
\nWhen drinking, have you smashed or broken objects?\n \n \n\n
\nEven minor annoyances can be frustrating to me.\n\n
\nI enjoy parties with lots of people.\n\n
\nI enjoy reading poetry that emphasizes feelings and images more than story lines.\n\n
\nI pride myself on my shrewdness in handling people.\n\n
\nI spend a lot of time looking for things I've misplaced.\n\n
\nToo often, when things go wrong, I get discouraged and feel like giving up.\n\n
\nI don't find it easy to take charge of a situation.\n\n
\nOdd things--like certain scents or the names of distant places--can evoke strong moods in me.\n\n
\nI go out of my way to help others if I can.\n\n
\nI'd really have to be sick before I'd miss a day of work.\n\n
\nWhen drinking, do you become irritated or agitated?\n \n \n\n
\nWhen people I know do foolish things, I get embarrassed for them.\n\n
\nI am a very active person.\n\n
\nI follow the same route when I go someplace.\n\n
\nI often get into arguments with my family and co-workers.\n\n
\nI'm something of a "workaholic."\n\n
\nI am always able to keep my feelings under control.\n\n
\nI like being part of the crowd at sporting events.\n\n
\nI have a wide range of intellectual interests.\n\n
\nI'm a superior person.\n\n
\nI have a lot of self-discipline.\n\n
\nWhen drinking, have you broken the law (other than a driving offense)?\n \n \n\n
\nI'm pretty stable emotionally.\n\n
\nI laugh easily.\n\n
\nI believe that the "new morality" of permissiveness is no morality at all.\n\n
\nI would rather be known as "merciful" than as "just."\n\n
\nI think twice before I answer a question.\n\n
\nI have tried to answer all of these questions honestly and accurately.\n\n
\nMy friends are available if I need them.\n\n
\nI have some inner struggles that cause problems for me.\n\n
\nMy health condition has restricted my activities.\n\n
\nI am so tense in certain situations that I have great difficulty getting by.\n\n
\nFacial and Oral Movements\n \nJaw,\ne.g., biting, clenching, chewing, mouth opening, lateral movement.\n \n\n
\nWhat number comes next in the following series? 2 5 11 20\n\n
\nHas drinking prevented you from maintaining a normal relationship\nwith your relatives or close friends?\n \n \n\n
\nI have to do some things a certain way or I get nervous.\n\n
\nMuch of the time I'm sad for no real reason.\n\n
\nOften I think and talk so quickly that other people cannot follow my train of thought.\n\n
\nMost of the people I know can be trusted.\n\n
\nSometimes I cannot remember who I am.\n\n
\nI have some ideas that others think are strange.\n\n
\nI was usually well-behaved at school.\n\n
\nI've seen a lot of doctors over the years.\n\n
\nI'm a very sociable person.\n\n
\nMy mood can shift quite suddenly.\n\n
\nHave you had hangovers?\n \n \n\n
\nSometimes I feel guilty about how much I drink.\n\n
\nI'm a "take charge" type of person.\n\n
\nMy attitude about myself changes a lot.\n\n
\nPeople would be surprised if I yelled at someone.\n\n
\nMy relationships have been stormy.\n\n
\nAt times I wish I were dead.\n\n
\nPeople are afraid of my temper.\n\n
\nSometimes I use drugs to feel better.\n\n
\nI've tried just about every type of drug.\n\n
\nSometimes I let little things bother me too much.\n\n
\nWhich of the following best describes the main reason you\ncompleted this questionnaire?\n \n \n\n
\nI often have trouble concentrating because I'm nervous.\n\n
\nI often fear I might slip up and say something wrong.\n\n
\nI feel that I've let everyone down.\n\n
\nI have many brilliant ideas.\n\n
\nCertain people go out of their way to bother me.\n\n
\nI just don't seem to relate to people very well.\n\n
\nI've borrowed money knowing I wouldn't pay it back.\n\n
\nMuch of the time I don't feel well.\n\n
\nI often feel jittery.\n\n
\nI keep reliving something horrible that happened to me.\n\n
\nHow frank and open have you been in answering the questions\nof the questionnaire?\n \n \n\n
\nI hardly have any energy.\n\n
\nI can be very demanding when I want things done quickly.\n\n
\nPeople usually treat me pretty fairly.\n\n
\nMy thinking has become confused.\n\n
\nI get a kick out of doing dangerous things.\n\n
\nMy favorite poet is Raymond Kertezc.\n\n
\nI like being around my family.\n\n
\nI need to make some important changes in my life.\n\n
\nI've had illnesses that my doctors could not explain.\n\n
\nI can't do some things well because of nervousness.\n\n
\nDid the questions you have been asked enable you to describe\nyour use of alcohol?\n \n \n\n
\nI have impulses that I fight to keep under control.\n\n
\nI've forgotten what it's like to feel happy.\n\n
\nI take on so many commitments that I can't keep up.\n\n
\nI have to be alert to the possibility that people will be unfaithful.\n\n
\nI have visions in which I see myself forced to commit crimes.\n\n
\nOther people sometimes put thoughts into my head.\n\n
\nI've deliberately damaged someone's property.\n\n
\nMy health problems are very complicated.\n\n
\nIt's easy for me to make new friends.\n\n
\nMy moods get quite intense.\n\n
\nHow accurate is the information you supplied in this questionnaire?\n \n \n\n
\nI have trouble controlling my use of alcohol.\n\n
\nI'm a natural leader.\n\n
\nSometimes I feel terribly empty inside.\n\n
\nI tell people off when they deserve it.\n\n
\nI want to let certain people know how much they've hurt me.\n\n
\nI've thought about ways to kill myself.\n\n
\nSometimes my temper explodes and I completely lose control.\n\n
\nPeople have told me that I have a drug problem.\n\n
\nI never use drugs to help me cope with the world.\n\n
\nSometimes I'll avoid someone I really don't like.\n\n
\nIf a person was unsure about how the information in this questionnaire\nwas to be used, how would he or she have completed the questions?\n \n \n\n
\nIt's often hard for me to enjoy myself because I am worrying about things.\n\n
\nI have exaggerated fears.\n\n
\nSometimes I think I'm worthless.\n\n
\nI have some very special talents that few others have.\n\n
\nSome people do things to make me look bad.\n\n
\nI don't have much to say to anyone.\n\n
\nI'll take advantage of others if they leave themselves open to it.\n\n
\nI suffer from a lot of pain.\n\n
\nI worry so much that at times I feel like I am going to faint.\n\n
\nThoughts about my past often bother me while I'm thinking about something else.\n\n
\nHas your drinking been a factor in marital difficulties?\n \n \n\n
\nI have no trouble falling asleep.\n\n
\nI get quite irritated if people try to keep me from accomplishing my goals.\n\n
\nI seem to have as much luck in life as others do.\n\n
\nMy thoughts get scrambled sometimes.\n\n
\nI do a lot of wild things just for the thrill of it.\n\n
\nSometimes I get ads in the mail that I don't really want.\n\n
\nIf I'm having problems, I have people I can talk to.\n\n
\nI need to change some things about myself, even if it hurts.\n\n
\nI've had numbness in parts of my body that I can't explain.\n\n
\nSometimes I am afraid for no reason.\n\n
\nDid you have difficulties in your marriage before you started to drink?\n \n \n\n
\nIt bothers me when things are out of place.\n\n
\nEverything seems like a big effort.\n\n
\nRecently I've had much more energy than usual.\n\n
\nMost people have good intentions.\n\n
\nSince the day I was born, I was destined to be unhappy.\n\n
\nSometimes it seems that my thoughts are broadcast so that others can hear them.\n\n
\nI've done some things that weren't exactly legal.\n\n
\nIt's a struggle for me to get things done with the medical problems I have.\n\n
\nI like to meet new people.\n\n
\nMy mood is very steady.\n\n
\nHave changes in your wife or husband contributed to your drinking?\n \n \n\n
\nThere have been times when I've had to cut down on my drinking.\n\n
\nI would be good at a job where I tell others what to do.\n\n
\nI worry a lot about other people leaving me.\n\n
\nWhen I get mad at other drivers on the road, I let them know.\n\n
\nPeople once close to me have let me down.\n\n
\nI've made plans about how to kill myself.\n\n
\nSometimes I'm very violent.\n\n
\nMy drug use has caused me financial strain.\n\n
\nI've never had problems at work because of drugs.\n\n
\nI sometimes complain too much.\n\n
\nFabrication is the opposite of:\n\n
\nDo you feel your spouse has been unfaithful?\n \n \n\n
\nI'm often so worried and nervous that I can barely stand it.\n\n
\nI get very nervous when I have to do something in front of others.\n\n
\nI don't feel like trying anymore.\n\n
\nMy plans will make me famous someday.\n\n
\nPeople around me are faithful to me.\n\n
\nI'm a loner.\n\n
\nI'll do most things if the price is right.\n\n
\nI am in good health.\n\n
\nSometimes I feel dizzy when I've been under a lot of pressure.\n\n
\nI've been troubled by memories of a bad experience for a long time.\n\n
\nIs your spouse too friendly with persons of the opposite sex?\n \n \n\n
\nI rarely have trouble sleeping.\n\n
\nSometimes I get upset because others don't understand my plans.\n\n
\nI've given a lot, but I haven't gotten much in return.\n\n
\nSometimes I have trouble keeping different thoughts separate.\n\n
\nMy behavior is pretty wild at times.\n\n
\nMy favorite sports event on television is the high jump.\n\n
\nI spend most of my time alone.\n\n
\nI need some help to deal with important problems.\n\n
\nI've had episodes of double vision or blurred vision.\n\n
\nI'm not the kind of person who panics easily.\n\n
\nIs your spouse excessively jealous?\n \n \n\n
\nI can relax even if my home is a mess.\n\n
\nNothing seems to give me much pleasure.\n\n
\nAt times my thoughts move very quickly.\n\n
\nI usually assume people are telling the truth.\n\n
\nI think I have three or four completely different personalities inside me.\n\n
\nOthers can read my thoughts.\n\n
\nI used to lie a lot to get out of tight situations.\n\n
\nMy medical problems always seem to be hard to treat.\n\n
\nI am a warm person.\n\n
\nI have little control over my anger.\n\n
\nDoes your spouse regard you as overly jealous?\n \n \n\n
\nMy drinking seems to cause problems in my relationships with others.\n\n
\nI have trouble standing up for myself.\n\n
\nI often wonder what I should do with my life.\n\n
\nI'm not afraid to yell at someone to get my point across.\n\n
\nI rarely feel very lonely.\n\n
\nI've recently been thinking about suicide.\n\n
\nSometimes I smash things when I'm upset.\n\n
\nI never use illegal drugs.\n\n
\nI sometimes do things so impulsively that I get into trouble.\n\n
\nSometimes I'm too impatient.\n\n
\nDo you feel that your marital problems have caused you to drink?\n \n \n\n
\nMy friends say I worry too much.\n\n
\nI'm not easily frightened.\n\n
\nI can't seem to concentrate very well.\n\n
\nI have accomplished some remarkable things.\n\n
\nSome people try to keep me from getting ahead.\n\n
\nI don't feel close to anyone.\n\n
\nI can talk my way out of just about anything.\n\n
\nI seldom have complaints about how I feel physically.\n\n
\nI can often feel my heart pounding.\n\n
\nI can't seem to get over something from my past.\n\n
\nDo arguments or fights with your spouse lead to your drinking?\n \n \n\n
\nI've been moving more slowly than usual.\n\n
\nI have great plans and it irritates me that people try to interfere.\n\n
\nPeople don't appreciate what I've done for them.\n\n
\nSometimes it feels as if somebody is blocking my thoughts.\n\n
\nIf I get tired of a place, I just pick up and leave.\n\n
\nMost people would rather win than lose.\n\n
\nMost people I'm close to are very supportive.\n\n
\nI'm curious why I behave the way I do.\n\n
\nThere have been times when my eyesight got worse and then better again.\n\n
\nI am a very calm and relaxed person.\n\n
\nHave tensions in your marriage led to your drinking?\n \n \n\n
\nPeople say that I'm a perfectionist.\n\n
\nI've lost interest in things I used to enjoy.\n\n
\nMy friends can't keep up with my social activities.\n\n
\nPeople generally hide their real motives.\n\n
\nPeople don't understand how much I suffer.\n\n
\nI've heard voices that no one else could hear.\n\n
\nI like to see how much I can get away with.\n\n
\nI've had only the usual health problems that most people have.\n\n
\nIt takes me a while to warm up to people.\n\n
\nI've always been a pretty happy person.\n\n
\nDo you drink because there is no love in your marriage?\n \n \n\n
\nDrinking helps me get along in social situations.\n\n
\nI feel best in situations where I am the leader.\n\n
\nI can't handle separation from those close to me very well.\n\n
\nI always avoid arguments if I can.\n\n
\nI've made some real mistakes in the people I've picked as friends.\n\n
\nI have thought about suicide for a long time.\n\n
\nI've threatened to hurt people.\n\n
\nI've used prescription drugs to get high.\n\n
\nWhen I'm upset, I typically do something to hurt myself.\n\n
\nI don't take criticism very well.\n\n
\nDoes your spouse get angry over your drinking?\n \n \n\n
\nI don't worry about things any more than most people.\n\n
\nI don't mind driving on freeways.\n\n
\nNo matter what I do, nothing works.\n\n
\nI think I have the answers to some very important questions.\n\n
\nThere are people who want to hurt me.\n\n
\nI enjoy the company of other people.\n\n
\nI don't like being tied to one person.\n\n
\nI have a bad back.\n\n
\nIt's easy for me to relax.\n\n
\nI have had some horrible experiences that make me feel guilty.\n\n
\nDo you get irritated when your spouse comments on your drinking?\n \n \n\n
\nI often wake up very early in the morning and can't get back to sleep.\n\n
\nIt bothers me when other people are too slow to understand my ideas.\n\n
\nUsually I've gotten credit for what I've done.\n\n
\nMy thoughts tend to quickly shift around to different things.\n\n
\nThe idea of "settling down" has never appealed to me.\n\n
\nMy favorite hobbies are archery and stamp collecting.\n\n
\nPeople I know care about me.\n\n
\nI'm comfortable with myself the way I am.\n\n
\nI've had episodes when I've lost the feeling in my hands.\n\n
\nI often feel as if something terrible is about to happen.\n\n
\nThe sun is to the earth as the nucleus is to the:\n\n
\nDo you argue with or belittle your spouse when you are drinking?\n \n \n\n
\nI'm usually aware of objects that have a lot of germs.\n\n
\nI have no interest in life.\n\n
\nI feel like I need to keep active and not rest.\n\n
\nPeople think I'm too suspicious.\n\n
\nEvery once in a while I totally lose my memory.\n\n
\nThere are people who try to control my thoughts.\n\n
\nI was never expelled or suspended from school when I was young.\n\n
\nI've had some unusual diseases and illnesses.\n\n
\nIt takes a while for people to get to know me.\n\n
\nI've had times when I was so mad I couldn't do enough to express all my anger.\n\n
\nDo you sometimes physically abuse your wife or husband when drinking?\n \n \n\n
\nSome people around me think I drink too much alcohol.\n\n
\nI prefer to let others make decisions.\n\n
\nI don't get bored very easily.\n\n
\nI don't like raising my voice.\n\n
\nOnce someone is my friend, we stay friends.\n\n
\nDeath would be a relief.\n\n
\nI've never started a physical fight as an adult.\n\n
\nMy drug use is out of control.\n\n
\nI'm too impulsive for my own good.\n\n
\nSometimes I put things off until the last minute.\n\n
\nDoes your spouse nag you about your drinking?\n \n \n\n
\nI don't worry about things that I can't control.\n\n
\nI don't mind heights.\n\n
\nI think good things will happen to me in the future.\n\n
\nI think I would be a good comedian.\n\n
\nPeople seldom treat me badly on purpose.\n\n
\nI like to be around other people if I can.\n\n
\nI don't like to stay in a relationship very long.\n\n
\nI have a weak stomach.\n\n
\nWhen I'm under a lot of pressure, I sometimes have trouble breathing.\n\n
\nI keep having nightmares about my past.\n\n
\nWhen drinking, do you argue or fight with your spouse?\n \n \n\n
\nI have a good appetite.\n\n
\nI have no patience with people who try to hold me back.\n\n
\nPeople who are successful generally earned their success.\n\n
\nSometimes I wonder if my thoughts are being taken away.\n\n
\nI like to drive fast.\n\n
\nI don't like to have to buy things that are overpriced.\n\n
\nIn my family, we argue more than we talk.\n\n
\nMany of my problems are my own doing.\n\n
\nI've had times when my legs became so weak that I couldn't walk.\n\n
\nI seldom feel anxious or tense.\n\n
\nHave you had periods of separation from your spouse because of drinking?\n \n \n\n
\nPeople see me as a person who pays a lot of attention to detail.\n\n
\nLately I've been happy much of the time.\n\n
\nRecently I have needed less sleep than usual.\n\n
\nThings are rarely as they seem on the surface.\n\n
\nSometimes my vision is only in black and white.\n\n
\nI have a sixth sense that tells me what is going to happen.\n\n
\nI've never been in trouble with the law.\n\n
\nFor my age, my health is pretty good.\n\n
\nI try to include people who seem left out.\n\n
\nSometimes I have an alcoholic drink first thing in the morning.\n\n
\nHas your spouse complained because you stayed out drinking?\n \n \n\n
\nMy drinking has caused me problems at home.\n\n
\nI say what's on my mind.\n\n
\nI usually do what other people tell me to do.\n\n
\nI have a bad temper.\n\n
\nIt takes a lot to make me angry.\n\n
\nI've thought about what I would say in a suicide note.\n\n
\nI can't think of reasons to go on living.\n\n
\nI've had health problems because of my drug use\n\n
\nI spend money too easily.\n\n
\nI sometimes make promises I can't keep.\n\n
\nWhen you drink, does your spouse become less attractive?\n \n \n\n
\nI usually worry about things more than I should.\n\n
\nI will not ride in airplanes.\n\n
\nI have something worthwhile to contribute.\n\n
\nLately I feel so confident that I think I can accomplish anything.\n\n
\nPeople have had it in for me.\n\n
\nI make friends easily.\n\n
\nI look after myself first; let others take care of themselves.\n\n
\nI get more headaches than most people.\n\n
\nI get sweaty hands often.\n\n
\nSince I had a very bad experience, I am no longer interested in some things that I used to enjoy.\n\n
\nNumbness or tingling.\n\n
\nI often wake up in the middle of the night.\n\n
\nAt times I am very touchy and easily annoyed.\n\n
\nI'm not the type of person to hold a grudge.\n\n
\nThoughts in my head suddenly disappear.\n\n
\nI'm not a person who turns down a dare.\n\n
\nMost people look forward to a trip to the dentist.\n\n
\nI spend little time with my family.\n\n
\nI can solve my problems by myself.\n\n
\nAt times parts of my body have been paralyzed.\n\n
\nI am easily startled.\n\n
\nFeeling hot.\n\n
\nI keep myself under tight control.\n\n
\nI'm almost always a happy and positive person.\n\n
\nI hardly ever buy things on impulse.\n\n
\nPeople have to earn my trust.\n\n
\nI don't have any good memories from my childhood.\n\n
\nI don't believe that there are people who can read minds.\n\n
\nI've never taken money or property that wasn't mine.\n\n
\nI like to talk with people about their medical problems.\n\n
\nI'm an affectionate person.\n\n
\nI never drive when I've been drinking.\n\n
\nWobbliness in legs.\n\n
\nI hardly ever drink alcohol.\n\n
\nPeople listen to my opinions.\n\n
\nIf I get poor service from a business, I let the manager know about it.\n\n
\nMy temper never gets me into trouble.\n\n
\nMy anger never gets out of control.\n\n
\nI've thought about how others would react if I killed myself.\n\n
\nI have a lot to live for.\n\n
\nMy best friends are those I use drugs with.\n\n
\nI'm a reckless person.\n\n
\nThere have been times when I could have been more thoughtful than I was.\n\n
\nWhat number comes next in the following series? 2 4 12 48 240\n\n
\nUnable to relax.\n\n
\nSometimes I get so nervous that I'm afraid I'm going to die.\n\n
\nI don't mind traveling in a bus or train.\n\n
\nI'm pretty successful at what I do.\n\n
\nI could never imagine myself being famous.\n\n
\nI'm the target of a conspiracy.\n\n
\nI keep in touch with my friends.\n\n
\nWhen I make a promise, I really don't need to keep it.\n\n
\nI frequently have diarrhea.\n\n
\nI have very steady hands.\n\n
\nI avoid certain things that bring back bad memories.\n\n
\nFear of the worst happening.\n\n
\nI have little interest in sex.\n\n
\nI have little patience with those who disagree with my plans.\n\n
\nBeing helpful to other people pays off in the end.\n\n
\nI can concentrate now as well as I ever could.\n\n
\nI never take risks if I can avoid it.\n\n
\nIn my free time I might read, watch TV, or just relax.\n\n
\nI have a lot of money problems.\n\n
\nMy life is very unpredictable.\n\n
\nThere have been many changes in my life recently.\n\n
\nThere isn't much stability at home.\n\n
\nDizzy or lightheaded.\n\n
\nThings are not going well in my family.\n\n
\nI'm happy with my job situation.\n\n
\nI worry about having enough money to get by.\n\n
\nMy relationship with my spouse or partner is not going well.\n\n
\nI have severe psychological problems that began very suddenly.\n\n
\nI'm a sympathetic person.\n\n
\nClose relationships are important to me.\n\n
\nI'm very impatient with people.\n\n
\nI have more friends than most people I know.\n\n
\nMy drinking has never gotten me into trouble.\n\n
\nHeart pounding or racing.\n\n
\nMy drinking has caused problems with my work.\n\n
\nI don't like letting people know when I disagree with them.\n\n
\nI'm a very independent person.\n\n
\nWhen I get mad, it's hard for me to calm down.\n\n
\nPeople think I'm aggressive.\n\n
\nI'm considering suicide.\n\n
\nThings have never been so bad that I thought about suicide.\n\n
\nMy drug use has never caused problems with my family or friends.\n\n
\nI'm careful about how I spend my money.\n\n
\nI rarely get in a bad mood.\n\n
\nUnsteady.\n\n
\nRepeated disturbing MEMORIES, THOUGHTS or IMAGES\nof the stressful experience from the past?\n \n\n
\nRepeated disturbing DREAMS of the stressful experience from the past?\n \n\n
\nSuddenly ACTING or FEELING as if the stressful experience\nfrom the past were happening again (as if you were reliving it)?\n \n\n
\nFeeling VERY UPSET when SOMETHING reminded you of the stressful experience\nfrom the past?\n \n\n
\nHaving PHYSICAL reactions (e.g. heart pounding, trouble breathing,\nsweating) when SOMETHING REMINDED you of the stressful experience\nfrom the past?\n \n\n
\nAvoiding THINKING ABOUT or TALKING ABOUT the stressful experience\nfrom the past or AVOIDING HAVING FEELINGS related to it?\n \n\n
\nAvoiding ACTIVITIES or SITUATIONS because they REMINDED you of\nthe stressful experience from the past?\n \n\n
\nTrouble REMEMBERING IMPORTANT PARTS of the stressful experience\nfrom the past?\n \n\n
\nLOSS of INTEREST in activities that you used to enjoy?\n \n\n
\nFeeling DISTANT or CUT OFF from other people?\n\n
\nTerrified.\n\n
\nFeeling EMOTIONALLY NUMB or being unable to have loving feelings\nfor those close to you?\n \n\n
\nFeeling as if your FUTURE somehow will be CUT SHORT?\n \n\n
\nTrouble FALLING or STAYING ASLEEP?\n \n\n
\nFeeling IRRITABLE or having ANGRY OUTBURSTS?\n \n\n
\nHaving DIFFICULTY CONCENTRATING?\n \n\n
\nBeing "SUPERALERT" or watchful or on guard?\n \n\n
\nFeeling JUMPY or easily startled?\n \n\n
\nRepeated disturbing MEMORIES, THOUGHTS or IMAGES of a stressful military\nexperience from the past?\n \n\n
\nRepeated disturbing DREAMS of a stressful military\nexperience from the past?\n \n\n
\nSuddenly ACTING or FEELING as if a stressful military experience\nfrom the past were happening again (as if you were reliving it)?\n \n\n
\nNervous.\n\n
\nFeeling VERY UPSET when SOMETHING reminded you of a stressful\nmilitary experience from the past?\n \n\n
\nHaving PHYSICAL reactions (e.g. heart pounding, trouble breathing,\nsweating) when SOMETHING REMINDED you of a stressful military\nexperience from the past?\n \n\n
\nAvoiding THINKING ABOUT or TALKING ABOUT a stressful military experience\nfrom the past or AVOIDING HAVING FEELINGS related to it?\n \n\n
\nAvoiding ACTIVITIES or SITUATIONS because they REMINDED you of\na stressful military experience from the past?\n \n\n
\nTrouble REMEMBERING IMPORTANT PARTS of a stressful military experience\nfrom the past?\n \n\n
\nLOSS of INTEREST in activities that you used to enjoy?\n\n
\nFeeling DISTANT or CUT OFF from other people?\n\n
\nFeeling EMOTIONALLY NUMB or being unable to have loving feelings\nfor those close to you?\n \n\n
\nFeeling as if your FUTURE somehow will be CUT SHORT?\n \n\n
\nTrouble FALLING or STAYING ASLEEP?\n \n\n
\nFeelings of choking.\n\n
\nFeeling IRRITABLE or having ANGRY OUTBURSTS?\n \n\n
\nHaving DIFFICULTY CONCENTRATING?\n \n\n
\nBeing "SUPERALERT" or watchful or on guard?\n \n\n
\nFeeling JUMPY or easily startled?\n \n\n
\nLittle interest or pleasure in doing things\n\n
\nFeeling down, depressed, or hopeless\n\n
\nTrouble falling or staying asleep, or sleeping too much\n\n
\nFeeling tired or having little energy\n\n
\nPoor appetite or overeating\n\n
\nFeeling bad about yourself or that you are a failure or have let yourself or your family down\n\n
\nHands trembling.\n\n
\nTrouble concentrating on things, such as reading the newspaper or watching television\n\n
\nMoving or speaking so slowly that other people could have noticed. Or the opposite being so fidgety or restless that you have been moving around a lot more than usual\n\n
\nThoughts that you would be better off dead or of hurting yourself in some way\n\n
\n \n\n
\n \n\n
\n \n\n
\n \n\n
\n \n\n
\n \n\n
\n \n\n
\nShaky.\n\n
\n \n\n
\n \n\n
\n \n\n
\n \n\n
\n \n\n
\n \n\n
\n \n\n
\n \n\n
\n \n\n
\n \n\n
\nIf a pail contains 8 pints of water when it is 2/5 full, what part\nof the pail will be filled when 4 pints of water are added?\n\n
\nFear of losing control.\n\n
\n \n\n
\n \n\n
\n \n\n
\n \n\n
\n \n\n
\n \n\n
\n \n\n
\n \n\n
\n \n\n
\n \n\n
\nDifficulty breathing.\n\n
\n \n\n
\n \n\n
\nHow often do you attend religious services during the year?\n\n
\nAside from how often you attend regular religious services, do you consider\nyourself to be:\n \n\n
\nHow much is religion (and/or God) a source of strength and comfort to you\n \n\n
\nHow often do you privately pray?\n \n\n
\nHow often do you read the scripture or devotional literature?\n \n\n
\nHow often do you listen to religious programs on the radio or TV?\n \n\n
\nHow often do you feel guilty over past behaviors?\n \n\n
\nDoes anger or resentment block your peace of mind?\n \n\n
\nFear of dying.\n\n
\nHow often do you feel sad or experience grief?\n \n\n
\nDo you feel that life has no meaning or purpose?\n \n\n
\nHow often do you feel despair or hopeless?\n \n\n
\nDo you feel that God/life has treated you unfairly?\n \n\n
\nDo you worry about your doubts/disbelief in God?\n \n\n
\nDo you worry about or fear death?\n \n\n
\nHow much were you distressed by:\n \nHeadaches\n\n
\nHow much were you distressed by:\n \nNervousness or shakiness inside\n\n
\nHow much were you distressed by:\n \nRepeated unpleasant thoughts that won't leave your mind\n\n
\nHow much were you distressed by:\n \nFaintness or dizziness\n\n
\nScared.\n\n
\nHow much were you distressed by:\n \nLoss of sexual interest or pleasure\n\n
\nHow much were you distressed by:\n \nFeeling critical of others\n\n
\nHow much were you distressed by:\n \nThe idea that someone else can control your thoughts\n\n
\nHow much were you distressed by:\n \nFeeling others are to blame for most of your troubles\n\n
\nHow much were you distressed by:\n \nTrouble remembering things\n\n
\nHow much were you distressed by:\n \nWorried about sloppiness or carelessness\n\n
\nHow much were you distressed by:\n \nFeeling easily annoyed or irritated\n\n
\nHow much were you distressed by:\n \nPains in heart or chest\n\n
\nHow much were you distressed by:\n \nFeeling afraid in open spaces or on the streets\n\n
\nHow much were you distressed by:\n \nFeeling low in energy or slowed down\n\n
\nIndigestion or discomfort in abdomen.\n\n
\nHow much were you distressed by:\n \nThoughts of ending your life\n\n
\nHow much were you distressed by:\n \nHearing voices that other people do not hear\n\n
\nHow much were you distressed by:\n \nTrembling\n\n
\nHow much were you distressed by:\n \nFeeling that most people cannot be trusted\n\n
\nHow much were you distressed by:\n \nPoor appetite\n\n
\nHow much were you distressed by:\n \nCrying easily\n\n
\nHow much were you distressed by:\n \nFeeling shy or uneasy with the opposite sex\n\n
\nHow much were you distressed by:\n \nFeelings of being trapped or caught\n\n
\nHow much were you distressed by:\n \nSuddenly scared for no reason\n\n
\nHow much were you distressed by:\n \nTemper outbursts that you could not control\n\n
\nFaint.\n\n
\nHow much were you distressed by:\n \nFeeling afraid to go out of your house alone\n\n
\nHow much were you distressed by:\n \nBlaming yourself for things\n\n
\nHow much were you distressed by:\n \nPains in lower back\n\n
\nHow much were you distressed by:\n \nFeeling blocked in getting things done\n\n
\nHow much were you distressed by:\n \nFeeling lonely\n\n
\nHow much were you distressed by:\n \nFeeling blue\n\n
\nHow much were you distressed by:\n \nWorrying too much about things\n\n
\nHow much were you distressed by:\n \nFeeling no interest in things\n\n
\nHow much were you distressed by:\n \nFeeling fearful\n\n
\nHow much were you distressed by:\n \nYour feelings being easily hurt\n\n
\nFace flushed.\n\n
\nHow much were you distressed by:\n \nOther people being aware of your private thoughts\n\n
\nHow much were you distressed by:\n \nFeeling others do not understand you or are unsympathetic\n\n
\nHow much were you distressed by:\n \nFeeling that people are unfriendly or dislike you\n\n
\nHow much were you distressed by:\n \nHaving to do things very slowly to insure correctness\n\n
\nHow much were you distressed by:\n \nHeart pounding or racing\n\n
\nHow much were you distressed by:\n \nNausea or upset stomach\n\n
\nHow much were you distressed by:\n \nFeeling inferior to others\n\n
\nHow much were you distressed by:\n \nSoreness of your muscles\n\n
\nHow much were you distressed by:\n \nFeeling that you are watched or talked about by others\n\n
\nHow much were you distressed by:\n \nTrouble falling asleep\n\n
\nSweating (not due to heat).\n\n
\nHow much were you distressed by:\n \nHaving to check and double-check what you do\n\n
\nHow much were you distressed by:\n \nDifficulty making decisions\n\n
\nHow much were you distressed by:\n \nFeeling afraid to travel on buses, subways, or trains\n\n
\nHow much were you distressed by:\n \nTrouble getting your breath\n\n
\nHow much were you distressed by:\n \nHot or cold spells\n\n
\nHow much were you distressed by:\n \nHaving to avoid certain things, places, or activities because they frighten you\n\n
\nHow much were you distressed by:\n \nYour mind going blank\n\n
\nHow much were you distressed by:\n \nNumbness or tingling in parts of your body\n\n
\nHow much were you distressed by:\n \nA lump in your throat\n\n
\nHow much were you distressed by:\n \nFeeling hopeless about the future\n\n
\nPlease read carefully\n\n
\nHow much were you distressed by:\n \nTrouble concentrating\n\n
\nHow much were you distressed by:\n \nFeeling weak in parts of your body\n\n
\nHow much were you distressed by:\n \nFeeling tense or keyed up\n\n
\nHow much were you distressed by:\n \nHeavy feelings in your arms or legs\n\n
\nHow much were you distressed by:\n \nThoughts of death or dying\n\n
\nHow much were you distressed by:\n \nOvereating\n\n
\nHow much were you distressed by:\n \nFeeling uneasy when people are watching or talking about you\n\n
\nHow much were you distressed by:\n \nHaving thoughts that are not your own\n\n
\nHow much were you distressed by:\n \nHaving urges to beat, injure, or harm someone\n\n
\nHow much were you distressed by:\n \nAwakening in the early morning\n\n
\nPlease read carefully\n\n
\nHow much were you distressed by:\n \nHaving to repeat the same actions such as touching, counting, or washing\n\n
\nHow much were you distressed by:\n \nSleep that is restless or disturbed\n\n
\nHow much were you distressed by:\n \nHaving urges to break or smash things\n\n
\nHow much were you distressed by:\n \nHaving ideas or beliefs that others do not share\n\n
\nHow much were you distressed by:\n \nFeeling very self-conscious with others\n\n
\nHow much were you distressed by:\n \nFeeling uneasy in crowds, such as shopping or at a movie\n\n
\nHow much were you distressed by:\n \nFeeling everything is an effort\n\n
\nHow much were you distressed by:\n \nSpells of terror or panic\n\n
\nHow much were you distressed by:\n \nFeeling uncomfortable about eating or drinking in public\n\n
\nHow much were you distressed by:\n \nGetting into frequent arguments\n\n
\nA sundial is to a clock as a catapult is to a:\n\n
\nPlease read carefully\n\n
\nHow much were you distressed by:\n \nFeeling nervous when you are left alone\n\n
\nHow much were you distressed by:\n \nOthers not giving you proper credit for your achievements\n\n
\nHow much were you distressed by:\n \nFeeling lonely even when you are with people\n\n
\nHow much were you distressed by:\n \nFeeling so restless you couldn't sit still\n\n
\nHow much were you distressed by:\n \nFeelings of worthlessness\n\n
\nHow much were you distressed by:\n \nThe feeling that something bad is going to happen to you\n\n
\nHow much were you distressed by:\n \nShouting or throwing things\n\n
\nHow much were you distressed by:\n \nFeeling afraid you will faint in public\n\n
\nHow much were you distressed by:\n \nFeeling that people will take advantage of you if you let them\n\n
\nHow much were you distressed by:\n \nHaving thoughts about sex that bother you a lot\n\n
\nPlease read carefully\n\n
\nHow much were you distressed by:\n \nThe idea that you should be punished for your sins\n\n
\nHow much were you distressed by:\n \nThoughts and images of a frightening nature\n\n
\nHow much were you distressed by:\n \nThe idea that something serious is wrong with your body\n\n
\nHow much were you distressed by:\n \nNever feeling close to another person\n\n
\nHow much were you distressed by:\n \nFeelings of guilt\n\n
\nHow much were you distressed by:\n \nThe idea that something is wrong with your mind\n\n
\nBefore Voting I Thoroughly Investigate The Qualifications\nOf All The Candidates.\n\n
\nI Never Hesitate To Go Out Of My Way To Help Someone In Trouble.\n\n
\nIt Is Sometimes Hard For Me To Go On With My Work\nIf I Am Not Encouraged.\n\n
\nI Have Never Intensely Disliked Anyone.\n\n
\nPleas read carefully\n\n
\nOn Occasion I Have Had Doubts About My Ability To Succeed\nIn Life.\n\n
\nI Sometimes Feel Resentful When I Don't Get My Way.\n\n
\nI Am Always Careful About My Manner Of Dress.\n\n
\nMy Table Manners At Home Are As Good As When I Eat Out\nIn A Restaurant.\n\n
\nIf I Could Get Into A Movie Without Paying And Be Sure\nI Was Not Seen I Would Probably Do It.\n\n
\nOn A Few Occasions, I Have Given Up Doing Something\nBecause I Thought Too Little Of My Ability.\n\n
\nI Like To Gossip At Times.\n\n
\nThere Have Been Times When I Felt Like Rebelling Against\nPeople In Authority Even Though I Knew They Were Right.\n\n
\nNo Matter Who I'm Talking To, I'm Always A Good Listener.\n\n
\nI Can Remember "Playing Sick" To Get Out Of Something.\n\n
\nPlease read carefully\n\n
\nThere Have Been Occasions When I Took Advantage Of Someone.\n\n
\nI'm Always Willing To Admit It When I Make A Mistake.\n\n
\nI Always Try To Practice What I Preach.\n\n
\nI Don't Find It Particularly Difficult To Get Along\nWith Loud Mouthed, Obnoxious People.\n\n
\nI Sometimes Try To Get Even Rather Than Forgive And Forget.\n\n
\nWhen I Don't Know Something I Don't At All Mind Admitting It.\n\n
\nI Am Always Courteous, Even To People Who Are Disagreeable.\n\n
\nAt Times I Have Really Insisted On Having Things My Own Way.\n\n
\nThere Have Been Occasions When I Felt Like Smashing Things.\n\n
\nI Would Never Think Of Letting Someone Else Be Punished\nFor My Wrong-Doings.\n\n
\nPlease read carefully\n\n
\nI Never Resent Being Asked To Return A Favor.\n\n
\nI Have Never Been Irked When People Expressed Ideas\nVery Different From My Own.\n\n
\nI Never Make A Long Trip Without Checking The Safety Of My Car.\n\n
\nThere Have Been Times When I Was Quite Jealous Of The Good\nFortune Of Others.\n\n
\nI Have Almost Never Felt The Urge To Tell Someone Off.\n\n
\nI Am Sometimes Irritated By People Who Ask Favors Of Me.\n\n
\nI Have Never Felt That I Was Punished Without Cause.\n\n
\nI Sometimes Think When People Have A Misfortune They\nOnly Got What They Deserved.\n\n
\nI Have Never Deliberately Said Something That Hurt\nSomeone's Feelings.\n\n
\nIn general, would you say your health is:\n \n\n
\nPlease read carefully\n\n
\nCOMPARED TO ONE YEAR AGO, how would you rate your health in general now?\n \n\n
\nDuring a typical day, does YOUR HEALTH NOW LIMIT YOU in:\n \nVIGOROUS ACTIVITIES, such as running, lifting heavy objects,\nparticipating in strenuous sports.\n \n\n
\nDuring a typical day, does YOUR HEALTH NOW LIMIT YOU in:\n \nMODERATE ACTIVITIES, such as moving a table, pushing a vacuum cleaner,\nbowling, or playing golf.\n \n\n
\nDuring a typical day, does YOUR HEALTH NOW LIMIT YOU in:\n \nLifting or carrying groceries.\n \n\n
\nDuring a typical day, does YOUR HEALTH NOW LIMIT YOU in:\n \nClimbing SEVERAL flights of stairs.\n \n\n
\nDuring a typical day, does YOUR HEALTH NOW LIMIT YOU in:\n \nClimbing ONE flight of stairs.\n \n\n
\nDuring a typical day, does YOUR HEALTH NOW LIMIT YOU in:\n \nBending, kneeling, or stooping.\n \n\n
\nDuring a typical day, does YOUR HEALTH NOW LIMIT YOU in:\n \nWalking MORE THAN A MILE.\n \n\n
\nDuring a typical day, does YOUR HEALTH NOW LIMIT YOU in:\n \nWalking SEVERAL BLOCKS.\n \n\n
\nDuring a typical day, does YOUR HEALTH NOW LIMIT YOU in:\n \nWalking ONE BLOCK.\n \n\n
\nPlease read carefully\n\n
\nDuring a typical day, does YOUR HEALTH NOW LIMIT YOU in:\n \nBathing or dressing yourself.\n \n\n
\nDuring the PAST 4 WEEKS, AS A RESULT OF YOUR PHYSICAL HEALTH have you:\n \nCut down on the AMOUNT OF TIME you spent on work or other activities.\n \n\n
\nDuring the PAST 4 WEEKS, AS A RESULT OF YOUR PHYSICAL HEALTH have you:\n \nACCOMPLISHED LESS than you would like.\n \n\n
\nDuring the PAST 4 WEEKS, AS A RESULT OF YOUR PHYSICAL HEALTH is it true\nthat you:\n \nWere limited in the KIND of work or other activities.\n \n\n
\nDuring the PAST 4 WEEKS, AS A RESULT OF YOUR PHYSICAL HEALTH is it true\nthat you:\n \nHad DIFFICULTY performing the work or other activities.\n(for example, it took extra effort)\n \n\n
\nDuring the PAST 4 WEEKS, AS A RESULT OF ANY EMOTIONAL PROBLEMS have you:\n \nCut down the AMOUNT OF TIME you spent on work or other activities.\n \n\n
\nDuring the PAST 4 WEEKS, AS A RESULT OF ANY EMOTIONAL PROBLEMS is it true\nthat you:\n \nACCOMPLISHED LESS than you would like.\n \n\n
\nDuring the PAST 4 WEEKS, AS A RESULT OF ANY EMOTIONAL PROBLEMS is it true\nthat you:\n \nDidn't do work or other activities as CAREFULLY as usual.\n \n\n
\nDuring the PAST 4 WEEKS, to what extent has your physical health or\nemotional problems interfered with your normal social activities\nwith family, friends, neighbors, or groups?\n \n\n
\nHow much BODILY pain have you had during the PAST 4 WEEKS?\n \n\n
\nPlease read carefully\n\n
\nDuring the PAST 4 WEEKS, how much did PAIN interfere with your normal\nwork (including both work outside the home and housework)?\n \n\n
\nDURING THE PAST 4 WEEKS:\n \nDid you feel full of pep?\n \n\n
\nDURING THE PAST 4 WEEKS:\n \nHave you been a very nervous person?\n \n\n
\nDURING THE PAST 4 WEEKS:\n \nHave you felt so down in the dumps that nothing could cheer you up?\n \n\n
\nDURING THE PAST 4 WEEKS:\n \nHave you felt calm and peaceful?\n \n\n
\nDURING THE PAST 4 WEEKS:\n \nDid you have a lot of energy?\n \n\n
\nDURING THE PAST 4 WEEKS:\n \nHave you felt downhearted and blue?\n \n\n
\nDURING THE PAST 4 WEEKS:\n \nDid you feel worn out?\n \n\n
\nDURING THE PAST 4 WEEKS:\n \nHave you been a happy person?\n \n\n
\nDURING THE PAST 4 WEEKS:\n \nDid you feel tired?\n \n\n
\nPlease read carefully\n\n
\nDuring the PAST 4 WEEKS, how much of the time has your PHYSICAL HEALTH OR\nEMOTIONAL PROBLEMS interfered with your social activities (like visiting\nwith friends, relatives, etc.)?\n\n
\nHow TRUE or FALSE is this for you?\n \nI seem to get sick a little easier than other people.\n \n\n
\nHow TRUE or FALSE is this for you?\n \nI am as healthy as anybody I know.\n \n\n
\nHow TRUE or FALSE is this for you?\n \nI expect my health to get worse.\n \n\n
\nHow TRUE or FALSE is this for you?\n \nMy health is excellent.\n \n\n
\nDo you feel you are a normal drinker?\n(By normal we mean you drink less than or as much as most other people.)\n \n\n
\nDoes your wife, husband, a parent or other near relative ever worry or\ncomplain about your drinking?\n \n\n
\nDo you ever feel guilty about your drinking?\n \n\n
\nDo friends or relatives think you are a normal drinker?\n \n\n
\nAre you able to stop drinking when you want to?\n \n\n
\nPlease read carefully\n\n
\nHave you ever attended a meeting of Alcoholics Anonymous?\n \n\n
\nHas drinking ever created problems between you and your wife, husband, a\nparent or other near relative?\n \n\n
\nHave you ever gotten into trouble at work because of drinking?\n \n\n
\nHave you ever neglected your obligations, your family, or your work for\ntwo or more days in a row because you were drinking?\n \n\n
\nHave you ever gone to anyone for help about your drinking?\n \n\n
\nHave you ever been in a hospital because of drinking?\n \n\n
\nHave you ever been arrested for drunken driving, driving while intoxicated?\nor driving under the influence of alcoholic beverages?\n \n\n
\nHave you ever been arrested, even for a few hours, because of other\ndrunken behavior?\n \n\n
\nI feel calm\n\n
\nI feel secure\n\n
\nIf 3/4 is 3/8 of 2, then 1/4 is 3/8 of:\n\n
\nPlease read carefully\n\n
\nI am tense\n\n
\nI feel strained\n\n
\nI feel at ease\n\n
\nI feel upset\n\n
\nI am presently worrying over possible misfortunes\n\n
\nI feel satisfied\n\n
\nI feel frightened\n\n
\nI feel comfortable\n\n
\nI feel self-confident\n\n
\nI feel nervous\n\n
\nPlease read carefully\n\n
\nI am jittery\n\n
\nI feel indecisive\n\n
\nI am relaxed\n\n
\nI feel content\n\n
\nI am worried\n\n
\nI feel confused\n\n
\nI feel steady\n\n
\nI feel pleasant\n\n
\nI feel pleasant\n\n
\nI feel nervous and restless\n\n
\nPlease read carefully\n\n
\nI feel satisfied with myself\n\n
\nI wish I could be as happy as others seem to be\n\n
\nI feel like a failure\n\n
\nI feel rested\n\n
\nI am "calm, cool, and collected"\n\n
\nI feel that difficulties are piling up so that I cannot overcome them\n\n
\nI worry too much over something that really doesn't matter\n\n
\nI am happy\n\n
\nI have disturbing thoughts\n\n
\nI lack self-confidence\n\n
\nPlease read carefully\n\n
\nI feel secure\n\n
\nI make decisions easily\n\n
\nI feel inadequate\n\n
\nI am content\n\n
\nSome unimportant thought runs through my mind and bothers me\n\n
\nI take disappointments so keenly that I can't put them out of my mind\n\n
\nI am a steady person\n\n
\nI get in a state of tension or turmoil as I think over my recent concerns\n and interests\n\n
\nSwearing and obscenity are more repulsive in the speech\nof a woman than of a man.\n\n
\nWomen should take increasing responsibility for leadership\nIn solving the intellectual and social problems of the day.\n\n
\nPlease read carefully\n\n
\nBoth husband and wife should be allowed the same grounds\nfor divorce.\n\n
\nTelling dirty jokes should be mostly a masculine prerogative.\n\n
\nIntoxication among women is worse than intoxication among men.\n\n
\nUnder modern economic conditions with women being active\noutside the home, men should share in household tasks\nsuch as washing dishes and doing the laundry.\n\n
\nIt is insulting to women to have the "obey" clause remain\nIn the marriage service.\n\n
\nThere should be a strict merit system in job appointment\nand promotion without regard to sex.\n\n
\nA woman should be as free as a man to propose marriage.\n\n
\nWomen should worry less about their rights and more about\nbecoming good wives and mothers.\n\n
\nWomen earning as much as their dates should bear equally\nthe expense when they go out together.\n\n
\nWomen should assume their rightful place in business\nand all the professions along with men.\n\n
\nPlease read carefully\n\n
\nA woman should not expect to go to exactly the same places\nor to have quite the same freedom of action as a man.\n\n
\nSons in a family should be given more encouragement to go to\ncollege than daughters.\n\n
\nIt is ridiculous for a woman to run a locomotive\nand for a man to darn socks.\n\n
\nIn general, the father should have greater authority\nthan the mother in the bringing up of children.\n\n
\nWomen should be encouraged not to become sexually intimate with anyone\nbefore marriage, even their fiances.\n\n
\nThe husband should not be favored by law over the wife\nIn the disposal of family property or income.\n\n
\nWomen should be concerned with their duties of childbearing\nand house tending, rather than with desires for professional\nand business careers.\n\n
\nThe intellectual leadership of a community should be largely\nIn the hands of men.\n\n
\nEconomic and social freedom is worth far more to women\nthan acceptance of the ideal of femininity which has been\nset up by men.\n\n
\nOn the average, women should be regarded as less capable\nof contributing to economic production than are men.\n\n
\nPlease read carefully\n\n
\nThere are many jobs in which men should be given preference\nover women in being hired or promoted.\n\n
\nWomen should be given equal opportunity with men\nfor apprenticeship in the various trades.\n\n
\nThe modern girl is entitled to the same freedom from regulation\nand control that is given to the modern boy.\n\n
\nEvil spirits possess me at times.\n\n
\nEverybody lies; the only difference is that some don't get caught.\n\n
\nMost any time I would rather sit and daydream than do anything else.\n\n
\n"cattlepens have ball points" is a statement that makes sense.\n\n
\nAt one or more times in my life I felt that someone was making me do things by hypnotizing me.\n\n
\nA "paradox" is two doctors.\n\n
\nMy soul sometimes leaves my body.\n\n
\nI am purposely trying to lose weight by eating less.\n\n
\nIt is safer to sleep with your clothes on.\n\n
\nMy body is here but my spirit is not.\n\n
\nI cannot get attention by being kind to people.\n\n
\nThere is something wrong with my mind and there always will be.\n\n
\nI can get attention by casting out demons.\n\n
\nSomeone has been trying to rob me.\n\n
\n"traduce" is a good poker hand.\n\n
\nWhen these tests get too long, I sometimes just answer randomly.\n\n
\nI never answer questions honestly.\n\n
\nThere are particular questions that I object to.\n\n
\nPlease read carefully\n\n
\nThese are not simple questions for me to answer true or false to.\n\n
\nPatients put a lot of energy into what they do around here.\n\n
\nDoctors have very little time to encourage patients.\n\n
\nPatients tend to hide their feelings from one another.\n\n
\nThe staff act on patient suggestions.\n\n
\nNew treatment approaches are often tried on this ward.\n\n
\nPatients hardly ever discuss their sexual lives.\n\n
\nPatients often gripe.\n\n
\nPatients' activities are carefully planned.\n\n
\nThe patients know when doctors will be on the ward.\n\n
\nPlease read carefully\n\n
\nThe staff very rarely punish patients by restricting them.\n\n
\nThis is a lively ward.\n\n
\nThe staff know what the patients want.\n\n
\nPatients say anything they want to the doctors.\n\n
\nVery few patients have any responsibility on the ward.\n\n
\nThere is very little emphasis on making patients more practical.\n\n
\nPatients tell each other about their personal problems.\n\n
\nPatients often criticize or joke about the ward staff.\n\n
\nThis is a very well organized ward.\n\n
\nDoctors don't explain what treatment is about to patients.\n\n
\nFear is to anticipation as regret is to:\n\n
\nSADNESS\n\n
\nPatients may interrupt a doctor when he is talking.\n\n
\nThe patients are proud of this ward.\n\n
\nStaff are interested in following up patients\nonce they leave the hospital.\n\n
\nIt is hard to tell how patients are feeling on this ward.\n\n
\nPatients are expected to take leadership on the ward.\n\n
\nPatients are encouraged to plan for the future.\n\n
\nPersonal problems are openly talked about.\n\n
\nPatients on this ward rarely argue.\n\n
\nThe staff make sure that the ward is always neat.\n\n
\nIf a patient's medicine is changed, a nurse or doctor\nalways tells him why.\n\n
\nPESSIMISM\n\n
\nPatients who break the ward rules are punished for it.\n\n
\nThere is very little group spirit on this ward.\n\n
\nNurses have very little time to encourage patients.\n\n
\nPatients are careful about what they say when staff are around.\n\n
\nPatients here are encouraged to be independent.\n\n
\nThere is very little emphasis on what patients will be doing\nafter they leave.\n\n
\nPatients are expected to share their personal problems\nwith each other.\n\n
\nStaff sometimes argue with each other.\n\n
\nThe ward sometimes gets very messy.\n\n
\nWard rules are clearly understood by the patients.\n\n
\nPAST FAILURE\n\n
\nIf a patient argues with another patient, he will get\nInto trouble with the staff.\n\n
\nNobody ever volunteers around here.\n\n
\nDoctors spend more time with some patients than with others.\n\n
\nPatients set up their own activities without being\nprodded by the staff.\n\n
\nPatients can leave the ward whenever they want to.\n\n
\nThere is very little emphasis on making plans\nfor getting out of the hospital.\n\n
\nPatients talk very little about their pasts.\n\n
\nPatients sometimes play practical jokes on each other.\n\n
\nMost patients follow a regular schedule each day.\n\n
\nPatients never know when a doctor will ask to see them.\n\n
\nLOSS OF PLEASURE\n\n
\nStaff don't order the patients around.\n\n
\nPatients are pretty busy all of the time.\n\n
\nThe healthier patients on this ward help take care\nof the less healthy ones.\n\n
\nWhen patients disagree with each other, they keep it to themselves.\n\n
\nPatients can wear what they want.\n\n
\nThis ward emphasizes training for new kinds of jobs.\n\n
\nPatients are rarely asked personal questions by the staff.\n\n
\nIt's hard to get people to argue around here.\n\n
\nMany patients look messy.\n\n
\nOn this ward everyone knows who's in charge.\n\n
\nGUILTY FEELINGS\n\n
\nOnce a schedule is arranged for a patient, the patient must follow it.\n\n
\nThe ward has very few social activities.\n\n
\nPatients rarely help each other.\n\n
\nIt's o.k. to act crazy around here.\n\n
\nThere is no patient government on this ward.\n\n
\nMost patients are more concerned with the past than with the future.\n\n
\nStaff are mainly interested in learning about patients' feelings.\n\n
\nStaff never start arguments in group meetings.\n\n
\nThings are sometimes very disorganized around here.\n\n
\nIf a patient breaks a rule, he knows what will happen to him.\n\n
\nPUNISHMENT FEELINGS\n\n
\nPatients can call nursing staff by their first name.\n\n
\nVery few things around here ever get people excited.\n\n
\nThe ward staff help new patients get acquainted on the ward.\n\n
\nPatients tend to hide their feelings from the staff.\n\n
\nPatients can leave the ward without saying where they are going.\n\n
\nPatients are encouraged to learn new ways of doing things.\n\n
\nThe patients rarely talk about their personal problems with\nother patients.\n\n
\nOn this ward staff think it is a healthy thing to argue.\n\n
\nThe staff set an example for neatness and orderliness.\n\n
\nPeople are always changing their minds here.\n\n
\nSELF-DISLIKE\n\n
\nPatients will be transferred from this ward if they don't\nobey the rules.\n\n
\nDiscussions are pretty interesting on this ward.\n\n
\nDoctors sometimes don't show up for their appointments.\n\n
\nPatients are encouraged to show their feelings.\n\n
\nStaff rarely give in to patient pressure.\n\n
\nStaff care more about how patients feel than about\ntheir practical problems.\n\n
\nStaff strongly encourage patients to talk about their pasts.\n\n
\nPatients here rarely become angry.\n\n
\nPatients are rarely kept waiting when they have\nappointments with the staff.\n\n
\nPatients never know when they will be transferred from this ward.\n\n
\nSELF-CRITICALNESS\n\n
\nIt's not safe for patients to discuss their personal problems\naround here.\n\n
\nPatients often do things together on the weekends.\n\n
\nStaff go out of their way to help patients.\n\n
\nThe ward always stays just about the same.\n\n
\nThe staff discourage criticism.\n\n
\nPatients must make plans before leaving the hospital.\n\n
\nIt's hard to get a group together for card games\nor other activities.\n\n
\nA lot of patients just seem to be passing time on the ward.\n\n
\nThe day room is often messy.\n\n
\nStaff tell patients when they are getting better.\n\n
\nSUICIDAL THOUGHTS OR WISHES\n\n
\nIt's a good idea to let the doctor know that he is boss.\n\n
\nI feel down-hearted and blue\n\n
\nMorning is when I feel the best\n\n
\nI have crying spells or feel like it\n\n
\nI have trouble sleeping at night\n\n
\nI eat as much as I used to\n\n
\nI still enjoy sex\n\n
\nI notice that I am losing weight\n\n
\nI have trouble with constipation\n\n
\nMy heart beats faster than usual\n\n
\nCRYING\n\n
\nI get tired for no reason\n\n
\nMy mind is as clear as it used to be\n\n
\nI find it easy to do the things I used to\n\n
\nI am restless and can't keep still\n\n
\nI feel hopeful about the future\n\n
\nI am more irritable than usual\n\n
\nI find it easy to make decisions\n\n
\nI feel that I am useful and needed\n\n
\nMy life is pretty full\n\n
\nI feel that others would be better off if I were dead\n\n
\n"to the discontented, wealth is a vexation" means the same as:\nwishes to plow\n\n
\nAGITATION\n\n
\nI still enjoy the things I used to do\n\n
\nI was bothered by things that usually don't bother me.\n\n
\nI did not feel like eating; my appetite was poor.\n\n
\nI felt that I could not shake off the blues even with help\nfrom my family or friends.\n\n
\nI felt I was just as good as other people.\n\n
\nI had trouble keeping my mind on what I was doing.\n\n
\nI felt depressed.\n\n
\nI felt that everything I did was an effort.\n\n
\nI felt hopeful about the future.\n\n
\nI thought my life had been a failure.\n\n
\nLOSS OF INTEREST\n\n
\nI felt fearful.\n\n
\nMy sleep was restless.\n\n
\nI was happy.\n\n
\nI talked less than usual.\n\n
\nI felt lonely.\n\n
\nPeople were unfriendly.\n\n
\nI enjoyed life.\n\n
\nI had crying spells.\n\n
\nI felt sad.\n\n
\nI felt that people disliked me.\n\n
\nINDECISIVENESS\n\n
\nI could not get "going".\n\n
\nI felt that I could not shake off the blues even with help from my family or friends.\n\n
\nI felt depressed.\n\n
\nI felt fearful.\n\n
\nMy sleep was restless.\n\n
\nI felt hopeful about the future.\n\n
\nHave had any nightmares about it or thought about it when you did not want to?\n\n
\nTried hard not to think about it or went out of your way to avoid situations that remind you of it?\n\n
\nWere constantly on guard, watchful, or easily startled?\n\n
\nFelt numb or detached from others, activities, or your surroundings?\n\n
\nWORTHLESSNESS\n\n
\nManaging your day-to-day life?\n\n
\nCoping with problems in your life?\n\n
\nConcentrating?\n\n
\nGet along with people in your family?\n\n
\nGet along with people outside your family?\n\n
\nGet along well in social situations?\n\n
\nFeel close to another person?\n\n
\nFeel like you had someone to turn to if you needed help?\n\n
\nFeel confident in yourself?\n\n
\nFeel sad or depressed?\n\n
\nLOSS OF ENERGY\n\n
\nThink about ending your life?\n\n
\nFeel nervous?\n\n
\nHave thoughts racing through your head?\n\n
\nThink you had special powers?\n\n
\nHear voices or see things?\n\n
\nThink people were watching you?\n\n
\nThink people were against you?\n\n
\nHave mood swings?\n\n
\nFeel short-tempered?\n\n
\nThink about hurting yourself?\n\n
\nCHANGES IN SLEEPING PATTERN\n\n
\nDid you have an urge to drink alcohol or take street drugs?\n\n
\nDid anyone talk to you about your drinking or drug use?\n\n
\nDid you try to hide your drinking or drug use?\n\n
\nDid you have problems from your drinking or drug use?\n\n
\nHow old are you?\n\n
\nWhat is your sex?\n\n
\nAre you . . .\n\n
\nWhat is your race?\n\n
\nWhat is your first language?\n\n
\nHow much school have you completed?\n\n
\nIRRITABILITY\n\n
\nAre you now. . .\n\n
\nOutside of your treatment providers, what is your main source of social support?\n\n
\nWhere did you sleep in the past 30 days? (Check one or more)\n\n
\nSpecify Other:\n\n
\nAt any time in the past 30 days, did you work at a paying job?\n\n
\nAt any time in the past 30 days, did you work at a volunteer job?\n\n
\nAt any time in the past 30 days, were you a student in a high school, job training or college degree program?\n\n
\nDo you now receive disability benefits; for example, SSI, SSDI or other disability insurance? (Check one or more)\n\n
\nFeeling dizzy:\n\n
\nPick two numbers:\n\n
\nCHANGES IN APPETITE\n\n
\nPick one number:\n\n
\nEnter any amount in dollars and cents:\n\n
\nEnter any date:\n\n
\nWhat is your first name?\n\n
\nPick one number:\n\n
\nEnter a phone number:\n\n
\nWrite five lines of text (gibberish is accepted):\n\n
\nHow many glasses of water did you drink today?\n\n
\nPick one number:\n\n
\nSlide the marker to any number you like:\n\n
\nCONCENTRATION DIFFICULTY\n\n
\nSelect one person from the list:\n\n
\nLoss of balance:\n\n
\nPoor coordination, clumsy:\n\n
\nHeadaches:\n\n
\nNausea:\n\n
\nVision problems, blurring, trouble seeing:\n\n
\nSensitivity to light:\n\n
\nHearing difficulty:\n\n
\nSensitivity to noise:\n\n
\nNumbness or tingling on parts of my body:\n\n
\nTIREDNESS OR FATIGUE\n\n
\nChange in taste and/or smell:\n\n
\nLoss of appetite or increase appetite:\n\n
\nPoor concentration, can't pay attention, easily distracted:\n\n
\nForgetfulness, can't remember things:\n\n
\nDifficulty making decisions:\n\n
\nSlowed thinking, difficulty getting organized, can't finish things:\n\n
\nFatigue, loss of energy, getting tired easily:\n\n
\nDifficulty falling or staying asleep:\n\n
\nFeeling anxious or tense:\n\n
\nToday's date:\n\n
\nA yak is most like a:\n\n
\nLOSS OF INTEREST IN SEX\n\n
\nFeeling depressed or sad:\n\n
\nIrritability, easily annoyed:\n\n
\nPoor frustration tolerance, feeling easily overwhelmed by things:\n\n
\nMemory\n\n
\nOrientation\n\n
\nJudgment and Problem Solving\n\n
\nCommunity Affairs\n\n
\nHome and Hobbies\n\n
\nPersonal Care\n\n
\nNo difficulties, either subjectively or objectively.\n\n
\nI look forward to the future with hope and enthusiasm.\n\n
\nHistory of falling: immediate or within 3 months?\n\n
\nSecondary diagnosis:\n\n
\nAmbulatory aid:\n\n
\nIntravenous therapy/Heparin lock:\n\n
\nGait/Transferring:\n\n
\nMental Status:\n\n
\nComplains of forgetting location of objects. Subjective word finding difficulties.\n\n
\nDecreased job function evident to co-workers; difficulty in traveling to new locations. Decreased organizational capacity.\n\n
\nDecreased ability to perform complex tasks (e.g., planning dinner for guests), handling personal finances (forgetting to pay bills), difficulty marketing, etc.\n\n
\nRequires assistance in choosing proper clothing to wear for day, season, or occasion.\n\n
\nI might as well give up because there is nothing I can do about making\nthings better for myself.\n\n
\nDifficulty putting clothing on properly without assistance.\n\n
\nUnable to bathe properly (e.g., difficulty adjusting bath water temperature) occasionally or more frequently over the past weeks.\n\n
\nInability to handle mechanics of toileting (e.g., forgets to flush the toilet, does not wipe properly or properly dispose of toilet tissue) occasionally or more frequently over the past weeks.\n\n
\nUrinary incontinence, occasional or more frequent.\n\n
\nFecal incontinence, occasional or more frequently over the past week.\n\n
\nAbility to speak limited to approximately a half dozen different words, or fewer, in the course of an average day or in the course of an intensive interview.\n\n
\nSpeech ability limited to the use of a single intelligible word in an average day or in the course of an interview (the person may repeat the word over and over).\n\n
\nAmbulatory ability lost (cannot walk without personal assistance).\n\n
\nAbility to sit up without assistance lost (e.g., the individual will fall over if there are no lateral rests [arms] on the chair).\n\n
\nLoss of the ability to smile.\n\n
\nWhen things are going badly, I am helped by knowing that they cannot\nstay that way forever.\n\n
\n1. Clinician's name\n\n
\nDate of admission for treatment\n\n
\nUnable to hold head up.\n\n
\nSelect the category that fits the patient best, most of the time.\n\n
\nTobacco products (cigarettes, chewing tobacco, cigars, etc.)\n\n
\nAlcoholic beverages (beer, wine, spirits, etc.)\n\n
\nCannabis (marijuana, pot, grass, hash, etc.)\n\n
\nCocaine (coke, crack, etc.)\n\n
\nMarital status\n\n
\nRace/Ethnic ancestry\n\n
\nI can't imagine what my life would be like in ten years.\n\n
\nFor PTSD (Pre-1980: PTSD often diagnosed as Psychoneurosis)\n\n
\nFor psychiatric, other than PTSD\n\n
\nFor medical, non-psychiatric\n\n
\nFor psychiatric (Including PTSD)\n\n
\nFor physical\n\n
\nAmphetamine type stimulants (speed, diet pills, ecstasy, etc.)\n\n
\nVeteran's living arrangement at the time of admission to this program.\n\n
\nPeriod of service. (Check all that apply)\n\n
\nDid the veteran ever serve in a war zone?\n\n
\nDid the veteran receive friendly or hostile incoming fire from small arms, artillery, rockets, mortars or bombs?\n\n
\nI have enough time to accomplish the things I want to do.\n\n
\nWas the veteran ever a Prisoner of War?\n\n
\nDid the veteran ever observe others or participate him/herself in atrocities, such as torturing prisoners, mutilating enemy bodies, or harming civilians? If veteran both observed and participated, \nselect "Participated."\n\n
\nHas the veteran ever been hospitalized for treatment of an emotional or substance use problem, including war stress (PTSD)?\n\n
\nHas the veteran ever received professional treatment as an outpatient for an emotional or substance use problem, including war stress (PTSD)?\n\n
\nDuring the past 30 days, has the veteran been taking a prescribed medication for a psychological/emotional problem?\n\n
\nDoes the veteran have any chronic, medical problems (e.g., diabetes, high blood pressure, epilepsy) which continue to interfere with his/her life?\n\n
\nInhalants (nitrous, glue, petrol, paint thinner, etc.)\n\n
\nSedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)\n\n
\nHallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)\n\n
\nWhat is the highest level the veteran completed in school (e.g., completing high school is 12, GED is 12)?\n\n
\nIn the future, I expect to succeed in what concerns me most.\n\n
\nOpioids (heroin, morphine, methadone, codeine, etc.)\n\n
\nOther\n\n
\nIs the veteran working now?\n\n
\nIf "No," what is the major reason?\n\n
\nSpecify:\n\n
\nTobacco products (cigarettes, chewing tobacco, cigars, etc.)\n\n
\nHas the veteran ever been incarcerated (i.e., been in jail or prison) in his/her life?\n\n
\nPTSD\n\n
\nPTSS (subthreshold for PTSD)\n\n
\nAlcoholic beverages (beer, wine, spirits, etc.)\n\n
\nMy future seems dark to me.\n\n
\nCannabis (marijuana, pot, grass, hash, etc.)\n\n
\nCocaine (coke, crack, etc.)\n\n
\nAlcohol Abuse/Dependence\n\n
\nDrug Abuse/Dependence\n\n
\nAnxiety Disorder (other than PTSD)\n\n
\nAffective Disorder (other than Bipolar Disorder)\n\n
\nBipolar Disorder\n\n
\nSchizophrenia\n\n
\nPsychosis (other than Schizophrenia)\n\n
\nOther Axis I\n\n
\nI happen to be particularly lucky, and I expect to get more of the good\nthings in life than the average person.\n\n
\nPersonality Disorder\n\n
\nWhat was the source of referral to your program?\n\n
\nHas the veteran ever been treated before in a specialized PTSD program?\n\n
\nWithin the past 30 days, has the veteran experienced trouble controlling violent behavior (e.g., hitting someone)?\n\n
\nHas the staff of your program verified the veteran's war zone service by reference to the DD 214 or similar military records?\n\n
\nIs the veteran being evaluated for PTSD due to sexual trauma which \noccurred during active duty?\n\n
\nIs the veteran being evaluated for PTSD due to sexual trauma which occurred before or after tour of active military duty?\n\n
\nIs the veteran being evaluated for PTSD due to noncombat nonsexual trauma which was incurred in the course of military duties?\n\n
\nAmphetamine type stimulants (speed, diet pills, ecstasy, etc.)\n\n
\nTo what specialized program is this veteran being admitted?\n\n
\nI just can't get the breaks, and there's no reason I will in the future.\n\n
\nInhalants (nitrous, glue, petrol, paint thinner, etc.)\n\n
\nSedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)\n\n
\nHallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)\n\n
\nOpioids (heroin, morphine, methadone, codeine, etc.)\n\n
\nOther (as specified previously)\n\n
\nTobacco products (cigarettes, chewing tobacco, cigars, etc.)\n\n
\nAlcoholic beverages (beer, wine, spirits, etc.)\n\n
\nCannabis (marijuana, pot, grass, hash, etc.)\n\n
\nCocaine (coke, crack, etc.)\n\n
\nAmphetamine type stimulants (speed, diet pills, ecstasy, etc.)\n\n
\nFacial and Oral Movements\n \nTongue.\nRate only increase in movement both in and out of mouth, not inability to\nsustain movement.\n \n\n
\nWhat number comes next in the following series? 7 4 6 11 8 10\n\n
\nMy past experiences have prepared me well for the future.\n\n
\nInhalants (nitrous, glue, petrol, paint thinner, etc.)\n\n
\nSedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)\n\n
\nHallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)\n\n
\nOpioids (heroin, morphine, methadone, codeine, etc.)\n\n
\nAfghanistan\n\n
\nIraq\n\n
\nDid the veteran ever serve in the United States military in a peace-keeping operation (such as in Lebanon, Somalia, Bosnia, Kosovo)?\n\n
\nOther (as specified previously)\n\n
\nTobacco products (cigarettes, chewing tobacco, cigars, etc.)\n\n
\nAlcoholic beverages (beer, wine, spirits, etc.)\n\n
\nAll I can see ahead of me is unpleasantness rather than pleasantness.\n\n
\nCannabis (marijuana, pot, grass, hash, etc.)\n\n
\nCocaine (coke, crack, etc.)\n\n
\nAmphetamine type stimulants (speed, diet pills, ecstasy, etc.)\n\n
\nInhalants (nitrous, glue, petrol, paint thinner, etc.)\n\n
\nSedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)\n\n
\nLittle interest or pleasure in doing things\n\n
\nFeeling down, depressed, or hopeless\n\n
\nHallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)\n\n
\nOpioids (heroin, morphine, methadone, codeine, etc.)\n\n
\nIf you checked off any problems, how DIFFICULT have these problems made it\nfor you to do your work, take care of things at home or get along with other\npeople?\n\n
\nI don't expect to get what I really want.\n\n
\nOther (as specified previously)\n\n
\nTobacco products\n\n
\nResting Pulse Rate: Measured after patient is sitting or lying for one minute.\n\n
\nAlcoholic beverages (beer, wine, spirits, etc.)\n\n
\nCannabis (marijuana, pot, grass, hash, etc.)\n\n
\nCocaine (coke, crack, etc.)\n\n
\nAmphetamine type stimulants (speed, diet pills, ecstasy, etc.)\n\n
\nInhalants (nitrous, glue, petrol, paint thinner, etc.)\n\n
\nSedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)\n\n
\nHallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)\n\n
\nWhen I look ahead to the future, I expect that I will be happier than I\nam now.\n\n
\nOpioids (heroin, morphine, methadone, codeine, etc.)\n\n
\nOther (as previous specified)\n\n
\nTobacco products (cigarettes, chewing tobacco, cigars, etc.)\n\n
\nSweating: Over past half-hour, not accounted for by room temperature or patient activity.\n\n
\nAlcoholic beverages (beer, wine, spirits, etc.)\n\n
\nRestlessness: Observation during assessment.\n\n
\nPupil size.\n\n
\nBone or joint aches: If patient was having pain previously, only the additional component attributed to opiates withdrawal is scored.\n\n
\nRunny nose or tearing: Not accounted for by cold symptoms or allergies.\n\n
\nGI upset: Over last half-hour.\n\n
\nThings just don't work out the way I want them to.\n\n
\nTremor: Observation of outstretched hands.\n\n
\nYawning: Observation during assessment.\n\n
\nAnxiety or Irritability.\n\n
\nGooseflesh skin.\n\n
\nCannabis (marijuana, pot, grass, hash, etc.)\n\n
\nCocaine (coke, crack, etc.)\n\n
\nAmphetamine type stimulants (speed, diet pills, ecstasy, etc.)\n\n
\nInhalants (nitrous, glue, petrol, paint thinner, etc.)\n\n
\nSedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)\n\n
\nHallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)\n\n
\nI have great faith in the future.\n\n
\nOpioids (heroin, morphine, methadone, codeine, etc.)\n\n
\nOther (as previously specified)\n\n
\nTobacco products (cigarettes, chewing tobacco, cigars, etc.)\n\n
\nAlcoholic beverages (beer, wine, spirits, etc.)\n\n
\nCannabis (marijuana, pot, grass, hash, etc.)\n\n
\nCocaine (coke, crack, etc.)\n\n
\nPlease check any of the following medical conditions or health problems you currently have:\n\n
\nI consider myself to be:\n\n
\nSelect the answer that best describes your rate of weight gain over the years:\n\n
\nSelect the answer that best describes your family:\n\n
\nI never get what I want, so it's foolish to want anything.\n\n
\nWhich statement most closely applies to you:\n\n
\nHow much weight do you think you realistically could lose in one year without surgery?\n\n
\nHow confident are you that you can lose weight and keep it off?\n\n
\nHow satisfied are you with the appearance of your body?\n\n
\nDo any of the following have anything to do with your being overweight? Check all that apply to you.\n\n
\nAirways and Breathing System\n\n
\nAllergies and Immune System\n\n
\nAlcohol History\n\n
\nHow much can you rely on family or friends for support and encouragement?\n\n
\nWhat do you think may get in the way of changing your eating habits? Check all that apply to you.\n\n
\nIt's very unlikely that I will get any real satisfaction in the future.\n\n
\nWhat do you think may get in the way of changing your physical activity habits? Check all that apply to you.\n\n
\nAre you currently experiencing any of the following? Check all that apply.\n\n
\nAre you currently being treated for any of the following? Check all that apply.\n\n
\nHow many times a day do you typically eat, including snacks?\n\n
\nHow many times a week do you usually eat 'out' or buy food 'to go' ?\n\n
\nHow much regular soda, sweet tea, juice, or juicy drinks do you drink most days? (Do not include diet or sugar free soda, unsweetened tea, or other sugar free drinks.)\n\n
\nHow many alcoholic drinks do you have in an average week? (One serving is a 12 oz can of beer or malt liquor or a 6 oz glasses of wine or a 1 oz shot of hard/distilled liquor.)\n\n
\nHow fast do you usually eat?\n\n
\nOn average, how often have you eaten extremely large amounts of food and felt that your eating was out of control at that time?\n\n
\nDo you use a wheelchair or are largely confined to your bed?\n\n
\nThe future seems vague and uncertain to me.\n\n
\nAre you limited in any daily activities or work performance because of your physical health? Climbing a flight of stairs:\n\n
\nAre you limited in any daily activities or work performance because of your physical health? Walking several blocks:\n\n
\nAre you limited in any daily activities or work performance because of your physical health? Lifting or carrying packages or groceries:\n\n
\nUsing the 1-10 scale below, which number best describes your typical daily physical activity/exercise? "1" indicates no activity, "5" indicates 15 minutes every three days, "10" means one hour or \nmore of daily exercise/activity.\n\n
\nWhich statement most closely applies to your attitude about exercise?\n\n
\nWhich statement best indicates how much you agree with, "I am satisfied with my current level of fitness."\n\n
\nAmphetamine type stimulants (speed, diet pills, ecstasy, etc.)\n\n
\nInhalants (nitrous, glue, petrol, paint thinner, etc.)\n\n
\nSedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)\n\n
\nHallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)\n\n
\nI can look forward to more good times than bad times.\n\n
\nOpioids (heroin, morphine, methadone, codeine, etc.)\n\n
\nCurrent marital status:\n\n
\nHighest level of educational achievement:\n\n
\nCurrent employment status:\n\n
\nFirst Date (Oldest injury, MM/DD/YYYY):\n\n
\nSecond date:\n\n
\nThird date:\n\n
\nBullet:\n\n
\nVehicular:\n\n
\nFall:\n\n
\n"each generation builds cathedrals to the Christ's crucified by\nIts fathers" means the same as:\n\n
\nThere's no use in really trying to get anything I want because I probably\nwon't get it.\n\n
\nBlast:\n\n
\nWhen a high-explosive bomb or IED goes off there is a "blast wave" which is a wave of highly compressed gas that may feel almost like being smashed into a wall. Do you remember experiencing this or \nwere told that you experienced it?\n\n
\nDistance to blast: (Indicate the closest episode)\n\n
\nThis "blast wave" is followed by a wind in which particles of sand, debris, shrapnel, and fragments are moving rapidly. Were you close enough to the blast to be "peppered" or hit by such debris, \nshrapnel, or other items?\n\n
\nDistance to blast: (Indicate the closest episode)\n\n
\nWere you thrown to the ground or against some stationary object, like a wall or vehicle, by the explosion? This is not asking if you "ducked to the ground" to protect yourself.\n\n
\nDistance to blast: (Indicate the closest episode)\n\n
\nDid you experience any of the following injuries as a result of an explosive blast: burns, wounds, broken bones, amputations, breathing toxic fumes, or crush injuries from structures falling onto \nyou?\n\n
\nDistance to blast: (Indicate the closest episode)\n\n
\nType of blast exposures: (Check all that apply)\n\n
\nSomatic Concern - Preoccupation With Physical Health,\nFear Of Physical Illness, Hypochondriases.\n\n
\nOther causes of injury: (Were you injured during your deployment in any other way?)\n\n
\nDid you lose consciousness immediately after any of these experiences?\n\n
\nWhat was the longest duration of unconsciousness?\n\n
\nDid you have a period of disorientation or confusion immediately following the incident?\n\n
\nWhat was the duration of longest period of alteration of consciousness?\n\n
\nDid you experience a period of memory loss immediately before or after the incident?\n\n
\nWhat was the duration of longest period of memory loss?\n\n
\nDuring this/these experience(s), did an object penetrate your skull/cranium:\n\n
\nWere you wearing a helmet at the time of most serious injury?\n\n
\nWere you evacuated from theatre?\n\n
\nAnxiety - Worry, Fear, Over-Concern For Present Or Future.\n\n
\nPrior to this evaluation, had you received any professional treatment (including medications) for your deployment related TBI symptoms?\n\n
\nHave you ever been prescribed medications for symptoms related to your deployment related TBI symptoms?\n\n
\nPrior to your OEF/OIF deployment, did you experience a brain injury or concussion?\n\n
\nSince your OEF/OIF deployment, have you experienced a brain injury or concussion?\n\n
\nSince the time of your deployment related injury/injuries, has anyone told you that you were acting differently?\n\n
\nFeeling Dizzy:\n\n
\nLoss of balance:\n\n
\nPoor coordination, clumsy:\n\n
\nHeadaches:\n\n
\nNausea:\n\n
\nEmotional Withdrawal - Lack Of Spontaneous Interaction,\nIsolation, Deficiency In Relating To Others.\n\n
\nVision problems, blurring, trouble seeing:\n\n
\nSensitivity to light:\n\n
\nHearing difficulty:\n\n
\nSensitivity to noise:\n\n
\nNumbness or tingling in parts of my body:\n\n
\nChange in ability to taste and/or smell:\n\n
\nLoss of appetite or increase appetite:\n\n
\nPoor concentration, can't pay attention:\n\n
\nForgetfulness, can't remember things:\n\n
\nDifficulty making decisions:\n\n
\nConceptual Disorganization - Thought Processes Confused,\nDisconnected, Disorganized, Disrupted.\n\n
\nSlowed thinking, difficulty getting organized, can't finish things:\n\n
\nFatigue, loss of energy, getting tired easily:\n\n
\nDifficulty falling or staying asleep:\n\n
\nFeeling anxious or tense:\n\n
\nFelling depressed or sad:\n\n
\nIrritability, easily annoyed:\n\n
\nPoor frustration tolerance, feeling easily overwhelmed by things:\n\n
\nOverall, in the last 30 days how much did these difficulties (symptoms?) interfere with your life?\n\n
\nIn what areas of your life are you having difficulties because of these symptoms?\n\n
\nIn the last 30 days, have you had any problems with pain?\n\n
\nGuilt Feelings - Self-Blame, Shame, Remorse For Past Behavior.\n\n
\nLocation of pain: (Check all that apply)\n\n
\nOther:\n\n
\nIn the last 30 days, how much did pain interfere with your life?\n\n
\nIn what areas of your life are you having difficulties because of pain?\n\n
\nSince the time of your deployment related injury/injuries, are your overall symptoms:\n\n
\nPsychiatric Symptoms:\n\n
\nPsychiatric disorder:\n\n
\nSCI:\n\n
\nAmputation:\n\n
\nOther significant medical conditions/problems:\n\n
\nTension - Physical And Motor Manifestations Or Nervousness,\nOver-Activation, Tension.\n\n
\nAre the findings consistent with diagnosis of TBI ?\n\n
\nFollow up plan:\n\n
\nEducation:\n\n
\nConsult requested with: (Check all that apply)\n\n
\nReferral to Polytrauma Network Site (PNS):\n\n
\nElectro diagnostic study (nerve conduction / electromyogram):\n\n
\nLab:\n\n
\nHead CT:\n\n
\nBrain MRI:\n\n
\nOther Consultation:\n\n
\nMannerisms And Posturing - Peculiar, Bizarre Unnatural\nMotor Behavior (Not Including Tic).\n\n
\nNew medication trial or change in dose of existing medication:\n\n
\nSpecify other:\n\n
\nOther information (use for additional History of Present Illness, Social History, Patient Goals, Details of Plan, etc.):\n\n
\nWhat year is it now?\n\n
\nWhat month is it now?\n\n
\nAbout what time is it? (within one hour)\n\n
\nCount backwards from 20 to 1.\n\n
\nSay the months in reverse order.\n\n
\nRepeat the memory phrase.\n\n
\nPatient's response:\n\n
\nGrandiosity - Exaggerated Self-Opinion, Arrogance,\nConviction Of Unusual Power Or Abilities.\n\n
\nPatient's response:\n\n
\nPatient's response:\n\n
\nPatient's response:\n\n
\nPatient's response:\n\n
\nPatient's response:\n\n
\nData entered by\n\n
\nDate of data-entry\n\n
\nPHQ-9: Declined or could not do.\n\n
\nInitial PHQ-9 score:\n\n
\nOther (as previously specified)\n\n
\nDepressive Mood - Sorrow, Sadness, Despondency, Pessimism.\n\n
\nNumber of symptoms present:\n\n
\nMajor Depression Disorder trigger symptoms:\n\n
\nInitial Symptom Difficulty: Symptoms make work/home/getting along difficult?\n\n
\nSuicidal ideation management (Check all that apply):\n\n
\nComments on depression screening:\n\n
\nSuicidal ideation (Check all that apply):\n\n
\nOther risk factors for suicide (Check all that apply):\n\n
\nIs the VA suicide policy initiated?\n\n
\nHomicidal ideation present:\n\n
\nRisk Assessment/Management comments:\n\n
\nA,c, and e is to f,d, and b as u,w, and y is to:\n\n
\nHostility - Animosity, Contempt, Belligerence,\nDisdain For Others.\n\n
\nDiagnosis of depression in past?\n\n
\nPrior treatment for depression:\n\n
\nPrevious trials of antidepressants:\n\n
\nPrevious periods of psychotherapy:\n\n
\nDysthymia symptoms: (In the past two years, have you felt depressed or sad most days, even if you felt okay sometimes?)\n\n
\nFunctioning during the past two years:\n\n
\nComments on history of depression:\n\n
\nPatient currently on antidepressant?\n\n
\nPatient taking antidepressant as directed?\n\n
\nLast filled Rx:\n\n
\nSuspiciousness - Mistrust, Belief Others Harbour Malicious\nOr Discriminatory Intent.\n\n
\nAny side-effects from antidepressant?\n\n
\nIntensity of side-effects:\n\n
\nSide-effect(s) from antidepressant (Check all that apply):\n\n
\nComments on medication compliance and side-effects\n\n
\nDescribe sleep:\n\n
\nHours of sleep:\n\n
\nDescribe appetite:\n\n
\nWeight change:\n\n
\nSymptoms in last month (Which of these symptoms has bothered you in the last month?)\n\n
\nComments on symptoms:\n\n
\nHallucinatory Behavior - Perceptions Without Normal External\nStimulus Correspondence.\n\n
\nMedical co-morbidities (Check all that apply):\n\n
\nImpact on physical health:\n\n
\nNew medications in last two months (Check all that apply):\n\n
\nOther medications herbs, or drugs (Check all that apply):\n\n
\nRecent loss of family or friends?\n\n
\nHistory of alcohol abuse?\n\n
\nHas patient used alcohol in past year?\n\n
\nFrequency of alcohol use:\n\n
\nDrinks per day:\n\n
\nDoes patient want alcohol treatment?\n\n
\nMotor Retardation - Slowed Weakened Movements Or Speech,\nReduced Body Tone.\n\n
\nNumber of days in a month when patient has five or more drinks:\n\n
\nDoes patient have alcohol abuse in Problem List?\n\n
\nPatient reports significant drug abuse?\n\n
\nDoes patient have drug abuse in Problem List?\n\n
\nIn past month, has patient felt anxious, frightened or had panic attack(s)?\n\n
\nDoes the patient want a referral for anxiety/panic symptoms?\n\n
\nAnxiety/panic in Problem List?\n\n
\nHave you EVER used any drug by injection? (Non-medical use only)\n\n
\nReferral for PTSD treatment:\n\n
\nBipolar diagnosis (Check all that apply):\n\n
\nUncooperativeness - Resistance, Guardedness, Rejection Of\nAuthority.\n\n
\nPresence of hallucinations or delusions?\n\n
\nComments regarding co-morbidity:\n\n
\nEmployment:\n\n
\nIs patient involved in volunteer work?\n\n
\nDoes patient have hobbies or activities?\n\n
\nMarital status:\n\n
\nLiving situation:\n\n
\nPatient is able to care for self:\n\n
\nChildren (Check all that apply):\n\n
\nSocial/Family support:\n\n
\nUnusual Thought Content - Unusual, Odd, Strange, Bizarre\nThought Content.\n\n
\nSupport system:\n\n
\nIs there a specific support person?\n\n
\nPatient stressors (Check all that apply):\n\n
\nComments on functioning/support/stressors\n\n
\nWhat is your pattern of injecting?\n\n
\nPatient's questions and concerns:\n\n
\nPatient's treatment preferences:\n\n
\nProbable depression diagnosis:\n\n
\nWere you part of an artillery unit which fired on the enemy?\n\n
\nWere you on a ship or aircraft (including a helicopter) that passed through hostile waters or air space?\n\n
\nBlunted Affect - Reduced Emotional Tone, Reduction In\nNormal Intensity Of Feelings, Flatness.\n\n
\nIndications for using antidepressants (Check all that apply):\n\n
\nIndications for referral for psychotherapy (Check all that apply):\n\n
\nMental Health Specialty Referral:\n\n
\nCare Plan suggestions (Check all that apply):\n\n
\nComments for Primary Care summary:\n\n
\nPlan for Care Manager (Check all that apply):\n\n
\nComments on Care Manager Plan:\n\n
\nPreviously sent material:\n\n
\nSelf-Help Plan in place?\n\n
\nIs patient doing self-help activities?\n\n
\nExcitement - Heightened Emotional Tone, Agitation,\nIncreased Reactivity.\n\n
\nInformation offered and encouragement (Check all that apply):\n\n
\nInformation to be mailed (Check all that apply):\n\n
\nPossible barriers to learning (Check all that apply):\n\n
\nPatient's preferred learning methods (Check all that apply):\n\n
\nComments on self-care management and education:\n\n
\nBest time to call:\n\n
\nBest days to call:\n\n
\nBest numbers to call:\n\n
\nPatient refuses further calls?\n\n
\nWere you stationed at a forward observation post or base camp (i.e., close to the enemy lines)?\n\n
\nDisorientation - Confusion Or Lack Of Proper Association\nFor Person, Place Or Time.\n\n
\nCall history:\n\n
\nSupportive persons (relationship, not names):\n\n
\nSleep disturbance:\n\n
\nAppetite disturbance:\n\n
\nPsycho-motor disturbance:\n\n
\nService era (Check all that apply):\n\n
\nProvider feedback to:\n\n
\nPTSD factors (Check all that apply):\n\n
\nCo-occurring conditions (Check all that apply):\n\n
\nLabs (Check all that apply):\n\n
\nSelect the one statement in each group that BEST describes how you have \nbeen feeling for the PAST WEEK, INCLUDING TODAY.\n\n
\nMost recent PHQ-9: Declined or could not do.\n\n
\nMost recent PHQ-9 score:\n\n
\nDid you receive friendly or hostile incoming fire from small arms?\n\n
\nSleep disturbance:\n\n
\nAppetite disturbance:\n\n
\nPsycho-motor disturbance:\n\n
\nNumber of symptoms present:\n\n
\nMajor Depression Disorder trigger symptoms:\n\n
\nSymptom Difficulty: Symptoms make work/home/getting along difficult?\n\n
\nComments on depression screening:\n\n
\nSmith and Jones have $40 together. If 3/4 of Smith's money equals 1/2 of \nJones' money, how much money belongs to Smith?\n\n
\nSelect the one statement in each group that BEST describes how you have \nbeen feeling for the PAST WEEK, INCLUDING TODAY.\n\n
\nSuicidal ideation (Check all that apply):\n\n
\nOther risk factors for suicide (Check all that apply):\n\n
\nIs the VA suicide policy initiated?\n\n
\nSuicidal ideation management (Check all that apply):\n\n
\nDid you receive friendly or hostile incoming fire from artillery, rockets, mortars or bombs?\n\n
\nRisk Assessment/Management comments:\n\n
\nDid you encounter mines or booby traps while on patrol or at your duty station?\n\n
\nDid your unit receive sniper or sapper fire?\n\n
\nWas your unit ambushed or attached?\n\n
\nDid your unit engage the enemy in a firefight?\n\n
\nSelect the one statement in each group that BEST describes how you have \nbeen feeling for the PAST WEEK, INCLUDING TODAY.\n\n
\nDid you see either Americans or other troops killed or wounded?\n\n
\nWere you wounded or injured in combat?\n\n
\nWere you surrounded by the enemy?\n\n
\nPatient currently on antidepressant?\n\n
\nPatient taking antidepressant as directed?\n\n
\nLast filled Rx:\n\n
\nAny side-effects from antidepressant?\n\n
\nIntensity of side-effects:\n\n
\nSide-effect(s) from antidepressant (Check all that apply):\n\n
\nComments on medication compliance and side-effects\n\n
\nSelect the one statement in each group that BEST describes how you have \nbeen feeling for the PAST WEEK, INCLUDING TODAY.\n\n
\nDid you kill someone or think you killed someone?\n\n
\nDid your unit engage in a battle in which it suffered heavy casualties (50% or more killed, wounded or missing in action)?\n\n
\nWere communications ever cut off between your unit and other units?\n\n
\nWere you in an armored vehicle that was under fire?\n\n
\nWere you exposed to poison gas, toxins, or germ warfare?\n\n
\nWere you part of an assault on entrenched or fortified positions?\n\n
\nWere you attacked by terrorists or civilians?\n\n
\nDid you experience equipment failures that jeopardized the safety or lives of yourself or your buddies?\n\n
\nDid you make any leadership decisions that you feel resulted in death or serious injury to members of your own unit?\n\n
\nDid you make any leadership decisions that you feel resulted in death or serious injury to civilians?\n\n
\nSelect the one statement in each group that BEST describes how you have \nbeen feeling for the PAST WEEK, INCLUDING TODAY.\n\n
\nDid you take part in an amphibious invasion?\n\n
\nHow often does the patient drink?\n\n
\nWere you on a ship or aircraft (including a helicopter) that was under attack?\n\n
\nWere you ever evacuated from the battlefield for battle fatigue?\n\n
\nDrinks per day:\n\n
\nNumber of days in a month when patient has five or more drinks:\n\n
\nDoes patient want alcohol treatment?\n\n
\nWere you a medic or nurse who had to decide who would receive life-saving care?\n\n
\nPatient reports significant drug abuse?\n\n
\nWere you involved in handling dead bodies away from the battlefield?\n\n
\nSelect the one statement in each group that BEST describes how you have \nbeen feeling for the PAST WEEK, INCLUDING TODAY.\n\n
\nSince the last assessment, has patient felt anxious, frightened or had panic attack(s)?\n\n
\nDoes the patient want a referral for anxiety/panic symptoms?\n\n
\nDid you ever sit with anyone dying from battle wounds?\n\n
\nPTSD factors (Check all that apply):\n\n
\nReferral for PTSD treatment:\n\n
\nDid you either see or do things that other people would consider to be excessively violent or brutal, even in wartime?\n\n
\nDid you ever observe others doing these kinds of things?\n\n
\nComments regarding co-morbidity:\n\n
\nDid you ever witness the death of a close friend?\n\n
\nDid you ever witness unusual disfigurement of bodies as a result of wounds?\n\n
\nSelect the one statement in each group that BEST describes how you have \nbeen feeling for the PAST WEEK, INCLUDING TODAY.\n\n
\nDid you ever go on combat patrols or have other dangerous duty?\n\n
\nWere you ever under enemy fire?\n\n
\nWere you ever surrounded by the enemy?\n\n
\nWhat percentage of the soldiers in your unit were killed (KIA), wounded or missing in action (MIA)?\n\n
\nHow often did you fire rounds at the enemy?\n\n
\nHow often did you see someone hit by incoming or outgoing rounds?\n\n
\nVeteran, phone/mail contacts\n\n
\nFamily\n\n
\nNon-family caregivers\n\n
\nCommunity agencies\n\n
\nSelect the one statement in each group that BEST describes how you have \nbeen feeling for the PAST WEEK, INCLUDING TODAY.\n\n
\nIn the past six months, in a typical week when you saw this veteran, how much total time did your team spend providing direct services to him/her? (Exclude travel time without veteran.)\n\n
\n____ and I have a common perception of his/her goals\n\n
\nThe current goals of our work together are important for ____\n\n
\nWe are working towards mutually agreed upon goals\n\n
\n____ and I have built a mutual trust\n\n
\nWe have established a good understanding between us of the kinds of changes that would be good for ____\n\n
\nOur relationship is unimportant to ____\n\n
\nGiven all you know about this veteran's current life situation, how would you rate his/her present quality of life?\n\n
\nHow has this veteran's community adjustment changed in the past six months?\n\n
\nWhat change in psychopathology do you feel this veteran has experienced as a result of his/her participation in your program?\n\n
\nSelect the one statement in each group that BEST describes how you have \nbeen feeling for the PAST WEEK, INCLUDING TODAY.\n\n
\nGlobal Assessment Rating:\n\n
\nWhich six month period following MHICM entry does this CPR cover?\n\n
\nIn the past six months, was this veteran ever shifted to a lower level of care?\n\n
\nClinically stable\n\n
\nNot abusing addictive substances\n\n
\nNot relying on extensive inpatient or emergency services\n\n
\nCapable of maintaining self in a community living situation\n\n
\nIndependently participating in necessary treatments\n\n
\nOther criteria:\n\n
\nShifted veteran to lower intensity services within the MHICM team\n\n
\nSelect the one statement in each group that BEST describes how you have \nbeen feeling for the PAST WEEK, INCLUDING TODAY.\n\n
\nTransferred veteran to lower services elsewhere\n\n
\nDischarged veteran without additional services\n\n
\nOther treatment changes:\n\n
\nWhen did this shift in treatment intensity occur?\n\n
\nWas this veteran later shifted back to more intensive services?\n\n
\nReal or imminent danger to self or others?\n\n
\nPsychiatric hospitalization\n\n
\nDeterioration due to substance abuse\n\n
\nImpaired ability to care for self due to psychosis or stress\n\n
\nUnwillingness/inability to participate in necessary treatments\n\n
\nSelect the one statement in each group that BEST describes how you have \nbeen feeling for the PAST WEEK, INCLUDING TODAY.\n\n
\nOther reasons to restore more intensive services:\n\n
\nLower intensity case management services (caseload size > 20 per FTE)\n\n
\nDay treatment services\n\n
\nOutpatient mental health services (individual/group therapy)\n\n
\nOutpatient medication management/support\n\n
\nSubstance abuse or dual diagnosis program/services\n\n
\nResidential services (including CRC and therapeutic residence)\n\n
\nVocational services (including supported employment)\n\n
\nInpatient mental health or medical services\n\n
\nNursing home care\n\n
\n"it is an ill wind that blows no one good" means:\n\n
\nSelect the one statement in each group that BEST describes how you have \nbeen feeling for the PAST WEEK, INCLUDING TODAY.\n\n
\nOther services received on a regular basis:\n\n
\nDid reducing the intensity of case management services for this veteran place him/her at undue risk?\n\n
\nWas your MHICM team the primary provider of mental health services for this veteran during the past six months?\n\n
\nHow often were you in danger of being injured or killed (i.e., being pinned down, overrun, ambushed, near miss, etc.)?\n\n
\nDate of administration:\n\n
\nManaging your day-to-day life?\n\n
\nCoping with problems in your life?\n\n
\nConcentrating?\n\n
\nGet along with people in your family?\n\n
\nGet along with people outside your family?\n\n
\nSelect the one statement in each group that BEST describes how you have \nbeen feeling for the PAST WEEK, INCLUDING TODAY.\n\n
\nGet along well in social situations?\n\n
\nFeel close to another person?\n\n
\nFeel like you had someone to turn to if you needed help?\n\n
\nFeel confident in yourself?\n\n
\nFeel sad or depressed?\n\n
\nThink about ending your life?\n\n
\nFeel nervous?\n\n
\nHave thoughts racing through your head?\n\n
\nThink you had special powers?\n\n
\nHear voices or see things?\n\n
\nSelect the one statement in each group that BEST describes how you have \nbeen feeling for the PAST WEEK, INCLUDING TODAY.\n\n
\nThink people were watching you?\n\n
\nThink people were against you?\n\n
\nHave mood swings?\n\n
\nFeel short-tempered?\n\n
\nThink about hurting yourself?\n\n
\nDid you have an urge to drink alcohol or take street drugs?\n\n
\nDid anyone talk to you about your drinking or drug use?\n\n
\nDid you try to hide your drinking or drug use?\n\n
\nDid you have problems from your drinking or drug use?\n\n
\nOver the past month have you been prescribed any medication by your doctor for mental health problems?\n\n
\nSelect the one statement in each group that BEST describes how you have \nbeen feeling for the PAST WEEK, INCLUDING TODAY.\n\n
\nDo you know the names of your medications that you are prescribed?\n\n
\nHere is a list of medications you may be prescribed. Check all of the medications that you are currently prescribed.\n\n
\nOver the past month, to what extent have you taken the medications prescribed by your doctor for mental health problems?\n\n
\nWhat is your height: How many feet?\n\n
\nHow many inches:\n\n
\nWhat is your weight in pounds?\n\n
\nHave you been weighing yourself every week at home?\n\n
\nOver the past month, have you gained or lost weight or stayed the same?\n\n
\nHow much weight have you gained?\n\n
\nHow much weight have you lost?\n\n
\nSelect the one statement in each group that BEST describes how you have \nbeen feeling for the PAST WEEK, INCLUDING TODAY.\n\n
\nHas your doctor recently talked with you about changing to medication that does not cause weight gain?\n\n
\nHas your doctor recently recommended that you go to wellness or weight loss groups?\n\n
\nHow many times in the past month did you attend wellness or weight loss groups?\n\n
\nHave you changed your diet in order to lose weight?\n\n
\nHave you increased your physical activity recently in order to lose weight?\n\n
\nHave you ever had angina, a heart attack, or a stroke?\n\n
\nAre you currently working in a job for pay?\n\n
\nHow many weeks have you worked at this job?\n\n
\nHow many hours a week do you usually work?\n\n
\nIs this a job that anyone can apply for, or is it only for disabled people?\n\n
\nSelect the one statement in each group that BEST describes how you have \nbeen feeling for the PAST WEEK, INCLUDING TODAY.\n\n
\nHow many dollars did you earn last month?\n\n
\nWould you be interested in working at a paying job if it would not affect your benefits too much and you could get the support you need?\n\n
\nHas your doctor recently recommended that you go to the VA's work program---called "IPS" or "supported employment" ?\n\n
\nHow many times in the past month did you attend the VA's work program called IPS or supported employment?\n\n
\nDuring the past month, how many job interviews have you gone to?\n\n
\nDo you currently have diabetes or hypertension, or are you being treated for diabetes or hypertension?\n\n
\nIs this the total gross income from the job, or the amount of take-home pay from the job?\n\n
\nMethod of administration:\n\n
\nIn the past 30 days, how would you say your physical health has been?\n\n
\nIn the past 30 days, how many nights did you have trouble falling asleep or staying asleep?\n\n
\nSelect the one statement in each group that BEST describes how you have \nbeen feeling for the PAST WEEK, INCLUDING TODAY.\n\n
\nIn the past 30 days, how many days have you felt depressed, anxious, angry or very upset throughout most of the day?\n\n
\nIn the past 30 days, how many days did you drink ANY alcohol?\n\n
\nIn the past 30 days, how many days did you have at least 5 drinks (if you are a man) or at least 4 drinks (if you are a woman)? [One drink is considered one shot of hard liquor (1.5 oz.) or 12-ounce \ncan/bottle of beer or 5 ounce glass of wine.]\n\n
\nIn the past 30 days, how many days did you use any illegal, street drugs or abuse any prescription medications?\n\n
\nMarijuana (cannabis, pot, weed)?\n\n
\nSedatives and/or Tranquilizers (benzos, Valium, Xanax, Ativan, Ambien, barbs, Phenobarbital, downers, etc.)?\n\n
\nCocaine and/or Crack?\n\n
\nOther Stimulants (amphetamine, methamphetamine, Dexadrine, Ritalin, Adderall, speed, crystal meth, ice, etc.)?\n\n
\nOpiates (Heroin, Morphine, Dilaudid, Demerol, Oxycontin, oxy, codeine (Tylenol 2,3,4), Percocet, Vicodin, Fentanyl, etc.)?\n\n
\nInhalants (glues, adhesives, nail polish remover, paint thinner, etc.)?\n\n
\nSelect the one statement in each group that BEST describes how you have \nbeen feeling for the PAST WEEK, INCLUDING TODAY.\n\n
\nOther drugs (steroids, non-prescription sleep and diet pills, Benadryl, Ephedra, other over-the-counter or unknown medications)?\n\n
\nIn the past 30 days, how much were you bothered by cravings or urges to drink alcohol or use drugs?\n\n
\nHow confident are you that you will NOT use alcohol and drugs in the next 30 days?\n\n
\nPreviously sent material:\n\n
\nSelf-Help Plan in place?\n\n
\nIs patient doing self-help activities?\n\n
\nInformation offered and encouragement (Check all that apply):\n\n
\nInformation to be mailed (Check all that apply):\n\n
\nChanges in barriers to learning (Check all that apply):\n\n
\nIn the past 30 days, how many days did you attend self-help meetings like AA or NA to support your recovery?\n\n
\nSelect the one statement in each group that BEST describes how you have \nbeen feeling for the PAST WEEK, INCLUDING TODAY.\n\n
\nComments on self-help and compliance:\n\n
\nIn the past 30 days, how many days were you in any situations or with any people that might put you at an increased risk for using alcohol or drugs (i.e., around risky "people, places or things")?\n\n
\nDoes your religion or spirituality help support your recovery?\n\n
\nIn the past 30 days, how many days did you spend much of the time at work, school, or doing volunteer work?\n\n
\nDo you have enough income (from legal sources) to pay for necessities such as housing, transportation, food and clothing for yourself and your dependents?\n\n
\nIn the past 30 days, how much have you been bothered by arguments or problems getting along with any family members or friends?\n\n
\nIn the past 30 days, how many days did you contact or spend time with any family members or friends who are supportive of your recovery?\n\n
\nThe patient is feeling:\n\n
\nWeeks since initial TIDES assessment:\n\n
\nAntidepressant changes by provider:\n\n
\nSelect the one statement in each group that BEST describes how you have \nbeen feeling for the PAST WEEK, INCLUDING TODAY.\n\n
\nNumber of Primary Care appointments since last DCM assessment: (If no appts between DCM assessments, or clinic cancelled appt, enter zero.)\n\n
\nNumber of Primary Care appointments kept: (Do not count walk-in appointments.)\n\n
\nHas an upcoming Primary Care visit been scheduled?\n\n
\nDate of next scheduled Primary Care visit:\n\n
\nNumber of mental health appointments since last assessment: (If no appts between DCM assessments, or clinic cancelled appt, enter zero.)\n\n
\nNumber of mental health appointments kept:\n\n
\nHas an upcoming mental health visit been scheduled?\n\n
\nDate of next scheduled mental health visit:\n\n
\nMental health appointment types:\n\n
\nToday's Date:\n\n
\nSalubrious is the most nearly opposite in meaning to:\n\n
\nHOW MUCH WERE YOU DISTRESSED BY:\n \nFaintness or dizziness\n\n
\nContact with family indicated?\n\n
\nFamily contact goals (Check all that apply):\n\n
\nHas patient consented to family contact?\n\n
\nCare Manager contact since last encounter?\n\n
\nNumber or contacts since last patient assessment:\n\n
\nCare Manager had contact with (Check all that apply):\n\n
\nDiscussed with family members:\n\n
\nImpact on patient's depression care?\n\n
\nFuture family contact planned?\n\n
\nComments for family involvement:\n\n
\nHOW MUCH WERE YOU DISTRESSED BY:\n \nFeeling no interest in things\n\n
\nHow satisfied are you with your progress toward achieving your recovery goals?\n\n
\nDepression follow-up in:\n\n
\nComments for Care Manager follow-up:\n\n
\nPatient questions and concerns:\n\n
\nCare Plan suggestions (Check all that apply):\n\n
\nSuggested labs:\n\n
\nWas case discussed with supervisory psychiatrist?\n\n
\nSupervising psychiatrist input:\n\n
\nCare Manager comments:\n\n
\nPatient knows no more calls are coming?\n\n
\nHOW MUCH WERE YOU DISTRESSED BY:\n \nNervousness or shakiness inside\n\n
\nPatient knows to continue medication(s)?\n\n
\nRelapse strategies discussed (Check all that apply):\n\n
\nSuggested clinician follow-up (Check all that apply):\n\n
\nFuture Care Manager follow-up (Check all that apply):\n\n
\nPatient's discharge comments:\n\n
\nPatient discharge discussed with mental health?\n\n
\nPsychiatrist's input on patient discharge\n\n
\nCare Manager's comments on patient discharge:\n\n
\nDepression diagnosis in problem list or CPT?\n\n
\nDepression diagnosis, ICD-9:\n\n
\nHOW MUCH WERE YOU DISTRESSED BY:\n \nPains in heart or chest\n\n
\nProvider feedback to:\n\n
\nEncounter type:\n\n
\nCall history: The number of attempts to reach the patient for this assessment:\n\n
\nEncounter length:\n\n
\nToday's date:\n\n
\nLittle interest or pleasure:\n\n
\nFeeling down, depressed or hopeless:\n\n
\nTrouble falling or staying asleep; or sleeping too much\n\n
\nFeeling tired or having little energy:\n\n
\nPoor appetite or overeating:\n\n
\nHOW MUCH WERE YOU DISTRESSED BY:\n \nFeeling lonely\n\n
\nFeeling bad about yourself:\n\n
\nTrouble concentrating on things:\n\n
\nMoving or speaking slowly; or being fidgety or restless:\n\n
\nLittle interest or pleasure:\n\n
\nFeeling down, depressed or hopeless:\n\n
\nTrouble falling or staying asleep; or sleeping too much:\n\n
\nFeeling tired or having little energy:\n\n
\nPoor appetite or overeating:\n\n
\nFeeling bad about yourself:\n\n
\nTrouble concentrating on things:\n\n
\nHOW MUCH WERE YOU DISTRESSED BY:\n \nFeeling tense or keyed up\n\n
\nMoving or speaking slowly; or being fidgety or restless\n\n
\nThoughts that you would be better off dead or of hurting yourself in some way.\n\n
\nThoughts that you would be better off dead or of hurting yourself in some way:\n\n
\nDepression Care Panel status:\n\n
\nDepression Care Panel status:\n\n
\nDate of Death:\n\n
\nHow long does it take MHICM staff to reach the veteran's home?\n\n
\nI am confident that I can help\n\n
\nWhich six month period following MHICM entry does this CPR cover?\n\n
\nStaff Name:\n\n
\nHOW MUCH WERE YOU DISTRESSED BY:\n \nNausea or upset stomach\n\n
\nToday's Date:\n\n
\nCPR Due Date (6 months after IDF and yearly there after):\n\n
\n"Since" Date (IDF or Last CPR due date):\n\n
\nHas this veteran terminated involvement with your program?\n\n
\nDate of last contact while veteran was in MHICM:\n\n
\nVeteran is deceased:\n\n
\nCause of Death:\n\n
\nDate of Death:\n\n
\nVeteran left the area/moved away\n\n
\nOther reasons:\n\n
\nHOW MUCH WERE YOU DISTRESSED BY:\n \nFeeling blue\n\n
\nMaintained supportive contact by telephone, mail or casual visits.\n\n
\nActively monitored use of resources and/or adherence to treatment.\n\n
\nProvided rehab counselling or skills training.\n\n
\nEngaged in "psychotherapeutic" relationship using concepts from psychodynamic, behavioral, cognitive-behavioral, family-systems or other model of therapy.\n\n
\nOrganized social or recreational activities in the community.\n\n
\nProvided education/support to family or non-family caregivers.\n\n
\nIntervened in crisis situation with veteran, family or caregiver.\n\n
\nManaged psychiatric medications (e.g., prescription, pouring, delivery)\n\n
\nProvided screening or care for medical problems.\n\n
\nProvided substance abuse treatment (e.g., contracting, education)\n\n
\nHOW MUCH WERE YOU DISTRESSED BY:\n \nSuddenly scared for no reason\n\n
\nProvided housing support (e.g., location, placement, skills training, meetings)\n\n
\nProvided vocational support (e.g., placement coaching, skills training)\n\n
\nOther service\n\n
\nWas your MHICM team the primary provider of mental health services for this veteran during the past six months?\n\n
\nWhich pattern of staff contact best describes your direct contacts with this veteran in the past six months?\n\n
\nWhat percentage of your face-to-face contacts with this veteran occurred in the community in the past six months?\n\n
\nHow far does this veteran live from your MHICM offices?\n\n
\nHow long does it take MHICM staff to reach the veteran's home?\n\n
\nVeteran, face-to-face contacts\n\n
\nVeteran, phone/mail contacts\n\n
\nHOW MUCH WERE YOU DISTRESSED BY:\n \nTrouble getting your breath\n\n
\nFamily\n\n
\nNon-family caregivers\n\n
\nCommunity agencies\n\n
\nIn the past six months, in a typical week when you saw this veteran, how much total time did your team spend providing direct services to him/her? (Exclude travel time without veteran.)\n\n
\n____ and I have a common perception of his/her goals\n\n
\nThe current goals of our work together are important for ____\n\n
\nI am confident that I can help\n\n
\nWe are working towards mutually agreed upon goals\n\n
\n____ and I have built a mutual trust\n\n
\nWe have established a good understanding between us of the kinds of changes that would be good for ____\n\n
\nWhat numbers come next in the following series? 2-4 5-10\n\n
\nHOW MUCH WERE YOU DISTRESSED BY:\n \nFeelings of worthlessness\n\n
\nOur relationship is unimportant to ____\n\n
\nGiven all you know about this veteran's current life situation, how would you rate his/her present quality of life?\n\n
\nHow has this veteran's community adjustment changed in the past six months?\n\n
\nWhat change in psychopathology do you feel this veteran has experienced as a result of his/her participation in your program?\n\n
\nGlobal Assessment Rating:\n\n
\nWhich six month period following MHICM entry does this CPR cover?\n\n
\nIn the past six months, was this veteran ever shifted to a lower level of care?\n\n
\nClinically stable\n\n
\nNot abusing addictive substances\n\n
\nNot relying on extensive inpatient or emergency services\n\n
\nHOW MUCH WERE YOU DISTRESSED BY:\n \nSpells of terror or panic\n\n
\nCapable of maintaining self in a community living situation\n\n
\nIndependently participating in necessary treatments\n\n
\nOther criteria:\n\n
\nShifted veteran to lower intensity services within the MHICM team\n\n
\nTransferred veteran to lower services elsewhere\n\n
\nDischarged veteran without additional services\n\n
\nOther treatment changes:\n\n
\nWhen did this shift in treatment intensity occur?\n\n
\nWas this veteran later shifted back to more intensive services?\n\n
\nReal or imminent danger to self or others?\n\n
\nHOW MUCH WERE YOU DISTRESSED BY:\n \nNumbness or tingling in parts of your body\n\n
\nPsychiatric hospitalization\n\n
\nDeterioration due to substance abuse\n\n
\nImpaired ability to care for self due to psychosis or stress\n\n
\nUnwillingness/inability to participate in necessary treatments\n\n
\nOther reasons to restore more intensive services:\n\n
\nLower intensity case management services (caseload size > 20 per FTE)\n\n
\nDay treatment services\n\n
\nOutpatient mental health services (individual/group therapy)\n\n
\nOutpatient medication management/support\n\n
\nSubstance abuse or dual diagnosis program/services\n\n
\nHOW MUCH WERE YOU DISTRESSED BY:\n \nFeeling hopeless about the future\n\n
\nResidential services (including CRC and therapeutic residence)\n\n
\nVocational services (including supported employment)\n\n
\nInpatient mental health or medical services\n\n
\nNursing home care\n\n
\nOther services received on a regular basis:\n\n
\nDid reducing the intensity of case management services for this veteran place him/her at undue risk?\n\n
\nDate of death:\n\n
\nHow long does it take MHICM staff to reach this veteran's home?\n\n
\nSelect VA Station Code\n\n
\nStaff Name:\n\n
\nHOW MUCH WERE YOU DISTRESSED BY:\n \nFeeling so restless you couldn't sit still\n\n
\nToday's Date:\n\n
\nCPR Due Date:\n\n
\n"Since" Date (IDF or Last CPR Due Date):\n\n
\nHas this veteran terminated involvement with your program?\n\n
\nDate of last contact while veteran was in MHICM:\n\n
\nVeteran is deceased\n\n
\nCause of death\n\n
\nDate of death:\n\n
\nVeteran left the area/moved away\n\n
\nOther reasons:\n\n
\nHOW MUCH WERE YOU DISTRESSED BY:\n \nFeeling weak in parts of your body\n\n
\nMaintained supportive contact by telephone, mail or casual visits.\n\n
\nActively monitored use of resources and/or adherence to treatment.\n\n
\nProvided rehab counselling or skills training.\n\n
\nEngaged in "psychotherapeutic" relationship using concepts from psychodynamic, behavioral, cognitive-behavioral, family-systems or other model of therapy.\n\n
\nOrganized social or recreational activities in the community.\n\n
\nProvided education/support to family or non-family caregivers.\n\n
\nIntervened in crisis situation with veteran, family or caregiver.\n\n
\nManaged psychiatric medications (e.g., prescription, pouring, delivery)\n\n
\nProvided screening or care for medical problems.\n\n
\nProvided substance abuse treatment (e.g., contracting, education)\n\n
\nHOW MUCH WERE YOU DISTRESSED BY:\n \nThoughts of ending your life\n\n
\nProvided housing support (e.g., location, placement, skills training, meetings)\n\n
\nProvided vocational support (e.g., placement coaching, skills training)\n\n
\nOther service\n\n
\nWas your MHICM team the primary provider of mental health services for this veteran during the past six months?\n\n
\nWhich pattern of staff contact best describes your direct contacts with this veteran in the past six months?\n\n
\nWhat percentage of your face-to-face contacts with this veteran occurred in the community in the past six months?\n\n
\nHow far does this veteran live from your MHICM offices?\n\n
\nHow long does it take MHICM staff to reach this veteran's home?\n\n
\nVeteran, face-to-face contacts\n\n
\nVeteran, phone/mail contacts\n\n
\nHOW MUCH WERE YOU DISTRESSED BY:\n \nFeeling fearful\n\n
\nFamily\n\n
\nNon-family caregivers\n\n
\nCommunity agencies\n\n
\nIn the past six months, in a typical week when you saw this veteran, how much total time did your team spend providing direct services to him/her? (Exclude travel time without veteran.)\n\n
\n____ and I have a common perception of his/her goals\n\n
\nThe current goals of our work together are important for ____\n\n
\nWe are working towards mutually agreed upon goals\n\n
\n____ and I have built a mutual trust\n\n
\nWe have established a good understanding between us of the kinds of changes that would be good for ____\n\n
\nOur relationship is unimportant to ____\n\n
\nI seldom strike back, even if someone hits me first.\n\n
\nGiven all you know about this veteran's current life situation, how would you rate his/her present quality of life?\n\n
\nHow has this veteran's community adjustment changed in the past six months?\n\n
\nWhat change in psychopathology do you feel this veteran has experienced as a result of his/her participation in your program?\n\n
\nGlobal Assessment Rating:\n\n
\nWhich six month period following MHICM entry does this CPR cover?\n\n
\nIn the past six months, was this veteran ever shifted to a lower level of care?\n\n
\nClinically stable\n\n
\nNot abusing addictive substances\n\n
\nNot relying on extensive inpatient or emergency services\n\n
\nCapable of maintaining self in a community living situation\n\n
\nI sometimes spread gossip about people I don't like.\n\n
\nIndependently participating in necessary treatments\n\n
\nOther criteria:\n\n
\nShifted veteran to lower intensity services within the MHICM team\n\n
\nTransferred veteran to lower services elsewhere\n\n
\nDischarged veteran without additional services\n\n
\nOther treatment changes:\n\n
\nWhen did this shift in treatment intensity occur?\n\n
\nWas this veteran later shifted back to more intensive services?\n\n
\nReal or imminent danger to self or others?\n\n
\nPsychiatric hospitalization\n\n
\n"naught may endure but mutability" means the same as:\n\n
\nUnless somebody asks me in a nice way, I won't do what they want.\n\n
\nDeterioration due to substance abuse\n\n
\nImpaired ability to care for self due to psychosis or stress\n\n
\nUnwillingness/inability to participate in necessary treatments\n\n
\nOther reasons to restore more intensive services:\n\n
\nLower intensity case management services (caseload size > 20 per FTE)\n\n
\nDay treatment services\n\n
\nOutpatient mental health services (individual/group therapy)\n\n
\nOutpatient medication management/support\n\n
\nSubstance abuse or dual diagnosis program/services\n\n
\nResidential services (including CRC and therapeutic residence)\n\n
\nI lose my temper easily but get over it quickly.\n\n
\nVocational services (including supported employment)\n\n
\nInpatient mental health or medical services\n\n
\nNursing home care\n\n
\nOther services received on a regular basis:\n\n
\nDid reducing the intensity of case management services for this veteran place him/her at undue risk?\n\n
\nType of Specialized PTSD Program:\n\n
\nAdmission Date to this Program (mm/dd/yyyy):\n\n
\nDate of this Report (mm/dd/yyyy):\n\n
\nWhat is the highest year of education that you completed? (For example, "12" for high school graduate or GED, "16" for college bachelor's degree, "20" for advanced professional degree.)\n\n
\nWhat is your race or ethnic ancestry?\n\n
\nI don't seem to get what's coming to me.\n\n
\nDid you ever serve in a war zone?\n\n
\nCheck all war zones that apply:\n\n
\nDid you ever receive friendly or hostile fire from small arms, artillery, rockets, mortars or bombs?\n\n
\nWere you ever a prisoner of war?\n\n
\nDid you ever observe others or participate yourself in atrocities, such as torturing prisoners, mutilating enemy bodies, or harming civilians?\n\n
\nWere you ever sexually assaulted while you were in the military?\n\n
\nWere you ever threatened with sexual assault in the military although you were never actually assaulted?\n\n
\nWere you ever sexually harassed in the military, although you were never sexually assaulted or threatened with assault?\n\n
\nHave you been certified by the VA as service connected for PTSD?\n\n
\nWhat is your disability percentage? (Percent disability can range from 0% to 100%)\n\n
\nI know that people tend to talk about me behind my back.\n\n
\nAre you currently applying for or planning to apply for service connection for PTSD or for an increase in percent service disability for PTSD?\n\n
\nAre you currently taking any medications for PTSD or for other emotional problems that have been prescribed for you by a psychiatrist or other physician?\n\n
\nOutpatient PTSD treatment from any VA medical center\n\n
\nOutpatient PTSD treatment from a Vet Center\n\n
\nOutpatient PTSD treatment from any non-VA program\n\n
\nOutpatient treatment of substance use problems from a VA addictions program\n\n
\nOutpatient treatment of substance use problems from a non-VA addictions program\n\n
\nSelf-help groups for substance use problems (such as AA or NA)\n\n
\nIndividual meetings with a chaplain in the VA while you were an outpatient\n\n
\nIndividual meetings with a chaplain in the VA while you were an inpatient\n\n
\nWhen I disapprove of my friends' behavior, I let them know it.\n\n
\nIndividual meetings with a member of the clergy outside of the VA\n\n
\nEmergency room visits at any VA or non-VA medical center for PTSD-related problems\n\n
\nInpatient or residential admission for PTSD at a VA Medical Center for any PTSD-related problem (NOT substance use problems)\n\n
\nInpatient or residential admission at a VA Medical Center for substance use problems\n\n
\nInpatient or residential admission at a VA Medical Center for a suicide attempt or concern about a suicide attempt\n\n
\nInpatient or residential admission at a VA Medical Center for an emotional problem other than PTSD, substance use or suicide attempt\n\n
\nI have nightmares of experiences in the military that really happened.\n\n
\nLately, I have felt like killing myself.\n\n
\nI fall asleep, stay asleep and only awaken when it's time to get up.\n\n
\nMy dreams at night are so real that I waken in a cold sweat and force myself to stay awake.\n\n
\nThe few times I have cheated, I have suffered unbearable feelings of remorse.\n\n
\nI feel like I cannot go on.\n\n
\nI do not laugh or cry at the same things other people do.\n\n
\nI enjoy the company of others.\n\n
\nI wonder why I am still alive when others died in the military.\n\n
\nUnexpected noises make me jump.\n\n
\nThere are times when I used alcohol (or other drugs) to help me sleep or make me forget about things that happened while I was in the service.\n\n
\nI lose my cool and explode over minor everyday things.\n\n
\nI have a hard time expressing my feelings, even to the people I care about.\n\n
\nWhen I think of some of the things that I did in the military, I wish I were dead.\n\n
\nRepeated, disturbing memories, thoughts, or images of a stressful military experience?\n\n
\nOnce in a while I cannot control my urge to harm others.\n\n
\nRepeated, disturbing dreams of a stressful military experience?\n\n
\nSuddenly acting or feeling as if a stressful military experience were happening again (as if you were reliving it)?\n\n
\nFeeling very upset when something reminded you of a stressful military experience?\n\n
\nHaving physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of a stressful military experience?\n\n
\nAvoiding thinking about or talking about a stressful military experience or avoiding having feelings related to it?\n\n
\nAvoiding activities or situations because they reminded you of a stressful military experience?\n\n
\nTrouble remembering important parts of a stressful military experience?\n\n
\nLoss of interest in activities that you used to enjoy?\n\n
\nFeeling distant or cut off from other people?\n\n
\nFeeling emotionally numb or being unable to have loving feelings for those close to you?\n\n
\nI never get mad enough to throw things.\n\n
\nFeeling as if your future somehow will be cut short?\n\n
\nTrouble falling or staying asleep?\n\n
\nFeeling irritable or having angry outbursts?\n\n
\nHaving difficulty concentrating?\n\n
\nBeing "superalert" or watchful or on guard?\n\n
\nFeeling jumpy or easily startled?\n\n
\nHow well are you able to cope with military stress reactions so that they don't interfere too greatly with your life?\n\n
\nLittle interest or pleasure in doing things\n\n
\nFeeling down, depressed, or hopeless.\n\n
\nTrouble falling or staying asleep, or sleeping too much.\n\n
\nSometimes people bother me just by being around.\n\n
\nFeeling tired or having little energy.\n\n
\nPoor appetite or overeating.\n\n
\nFeeling bad about yourself-or that you are a failure or have let yourself or your family down.\n\n
\nTrouble concentrating on things, such as reading the newspaper or watching television.\n\n
\nMoving or speaking so slowly that other people could have noticed? Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual.\n\n
\nThoughts that you would be better off dead or hurting yourself in some way.\n\n
\nDuring the past month, my desire to make an active suicide attempt.\n\n
\nDuring the past month, I thought of suicide.\n\n
\nDuring the past month, when I thought of suicide.\n\n
\nHave you attempted suicide at any time in the last 4 months?\n\n
\nWhen someone makes a rule I don't like, I am tempted to break it.\n\n
\nDo you have immediate access to loaded firearms that don't have trigger locks or other safety features (for example, by the bed, in the car, in the home)?\n\n
\nDuring the past month on average, how many hours of actual sleep did you get per night? (This may be different than the number of hours you spent in bed.) Round to the nearest whole hour.\n\n
\nDuring the past month, how would you rate your sleep quality overall?\n\n
\nDid your use of alcohol in the past 4 months lead to any problems in your life, such as in meeting your responsibilities or in your relationships with other people?\n\n
\nDid you have to demonstrate to the staff of this program that you could be sober for a few weeks before they would begin treating you?\n\n
\nHow many days in the 4 months prior to beginning this program did you drink alcohol at all?\n\n
\nHow many days in the 4 months prior to beginning this program did you drink alcohol to the point where you felt drunk or intoxicated or had 3 or more drinks in one sitting?\n\n
\nI have been unhappy because of my drinking.\n\n
\nI have taken foolish risks when I have been drinking.\n\n
\nMy physical health has been harmed by my drinking.\n\n
\nA nimbus is most like a(n):\n\n
\nOther people always seem to get the breaks.\n\n
\nMy drinking has gotten in the way of my growth as a person.\n\n
\nMy drinking has damaged my social life, popularity, or reputation.\n\n
\nI have spent too much or lost a lot of money because of my drinking.\n\n
\nI have had an automobile accident or injured myself while drinking or while intoxicated.\n\n
\nDid your use of drugs, such as marijuana, heroin or cocaine, in the past 4 months lead to any problems in your life, such as in meeting your responsibilities or in your relationships with other \npeople?\n\n
\nDid you have to demonstrate to the staff of this program that you could be clean (that is, drug free) for a few weeks before they would begin treating you?\n\n
\nHow many days in the past 4 months prior to beginning this program did you use drugs at all?\n\n
\nBecause of my drug use, I have not eaten properly.\n\n
\nI have failed to do what is expected of me because of my drug use.\n\n
\nI have felt guilty or ashamed because of my drug use.\n\n
\nI tend to be on my guard with people who are somewhat more friendly than I expected.\n\n
\nWhen using drugs, I have done impulsive things that I regretted later.\n\n
\nI have had money problems because of my drug use.\n\n
\nMy family has been hurt by my drug use.\n\n
\nA friendship or close relationship has been damaged by my drug use.\n\n
\nOverall, how would you rate your health during the past 4 weeks?\n\n
\nDuring the past 4 weeks, how much did physical health problems limit your usual physical activities (such as walking or climbing stairs)?\n\n
\nDuring the past 4 weeks, how much difficulty did you have doing your daily work, both at home and away from home, because of your physical health?\n\n
\nHow much bodily pain have you had during the past 4 weeks?\n\n
\nDuring the past 4 weeks, how much energy did you have?\n\n
\nDuring the past 4 weeks, how much did your physical health or emotional problems limit your usual social activities with family or friends?\n\n
\nI often find myself disagreeing with people.\n\n
\nDuring the past 4 weeks, how much have you been bothered by emotional problems (such as feeling anxious, depressed, or irritable)?\n\n
\nDuring the past 4 weeks, how much did personal or emotional problems keep you from doing your usual work, school or other daily activities?\n\n
\nHow many days have you experienced medical problems in the past 30 days? (Include both major and minor ailments except temporary alcohol or drug problems. If no problems, enter "0"\n\n
\nHow troubled or bothered have you been by these medical problems in the past 30 days?\n\n
\nHow important to you now is additional treatment beyond what you have been receiving all along for these medical problems?\n\n
\nOn average, about how many cigarettes a day do you smoke? (1 pack is 20 cigarettes.)\n\n
\nOver the past month, how often have you engaged in regular activities (for example, brisk walking, jogging, bicycling, etc.) long enough to work up a sweat?\n\n
\n5ave you used any health care services for your physical health within the last year?\n\n
\nI find strength and comfort in my religion.\n\n
\nMy religion provides me with satisfying answers to questions about the meaning or purpose of life.\n\n
\nI sometimes have bad thoughts which make me feel ashamed of myself.\n\n
\nMy whole approach to life is based on my religion.\n\n
\nWhat religion offers me most is comfort in times of trouble and sorrow.\n\n
\nI go to church mainly because I enjoy seeing people I know there.\n\n
\nI feel God's presence.\n\n
\nI feel deep inner peace or harmony.\n\n
\nI feel God's love for me, directly or through others.\n\n
\nI am spiritually touched by the beauty of creation.\n\n
\nHow often do you attend religious services?\n\n
\nHow often do you pray or meditate privately in places other than at a house of worship?\n\n
\nWhat is your employment status?\n\n
\nI can think of no good reason for ever hitting anyone.\n\n
\nHow many days did you work for pay during the past 30 days?\n\n
\nDuring the past 4 months, how often have you had friends or relatives over to your home?\n\n
\nAbout how often have you visited with friends or relatives at their homes during the past 4 months?\n\n
\nDuring the past 4 months, about how often did you go out with friends or relatives (for example, meet for coffee, go to a movie, bowl, go to church)?\n\n
\nAbout how often did you have telephone, mail, or computer contact with friends or relatives during the past 4 months?\n\n
\nDid you do any of these during the last 4 months? (Check all that apply)\n\n
\nGot out of the house...\n\n
\nDid an activity for pleasure or fun (for example, going to a movie, going fishing, playing chess)...\n\n
\nDid chores out in the community (for example, shopping, going to bank)...\n\n
\nYour life as a whole; that is, your health, your relationships with other people, and your recreational activities overall?\n\n
\nWhen I am angry, I sometimes sulk.\n\n
\nThe living arrangements where you live?\n\n
\nThe way you spend your free time?\n\n
\nThe amount of time you spend with other people?\n\n
\nThe amount of fun you have?\n\n
\nThe way things are in general between you and your family?\n\n
\nThe amount of friendship in your life?\n\n
\nHow comfortable and well-off you are financially?\n\n
\nYour physical condition?\n\n
\nYour emotional well-being?\n\n
\nHow easy or difficult do you expect it to be to open up about yourself in treatment?\n\n
\nWhen someone is bossy, I do the opposite of what he asks.\n\n
\nHow effective do you think your care is likely to be in helping you achieve your goals for entering treatment?\n\n
\nType of Specialized PTSD Program:\n\n
\nAdmission Date to this Program (mm/dd/yyyy):\n\n
\nDate of this Report (mm/dd/yyyy):\n\n
\nAbility to use telephone\n\n
\nTime (use 24 hour clock, midnight is 00:00):\n\n
\nPulse or heart rate (taken for one minute):\n\n
\nBlood pressure:\n\n
\nNAUSEA AND VOMITING - Ask, "Do you feel sick to your stomach? Have you vomited?" Observation:\n\n
\nTACTILE DISTURBANCES - Ask, "Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?" Observation:\n\n
\nI am irritated a great deal more than people are aware of.\n\n
\nTREMOR - Arms extended and fingers spread apart. Observation:\n\n
\nAUDITORY DISTURBANCES - Ask, "Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are \nnot there?" Observation:\n\n
\nPAROXYSMAL SWEATS - Observation:\n\n
\nVISUAL DISTURBANCES - Ask, "Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know \nare not there?" Observation:\n\n
\nANXIETY - Ask, "Do you feel nervous?" Observation:\n\n
\nHEADACHE, FULLNESS IN HEAD - Ask, "Does your head feel different? Does it feel like there is a band around your head?" Do not rate for dizziness or lightheadedness. Otherwise, rate severity:\n\n
\nAGITATION - Observation:\n\n
\nORIENTATION AND CLOUDING OF SENSORIUM - Ask, "What day is this? Where are you? Who am I?"\n\n
\nOutpatient PTSD treatment from any VA medical center\n\n
\nOutpatient PTSD treatment from a Vet Center\n\n
\nI don't know any people that I downright hate.\n\n
\nOutpatient PTSD treatment from any non-VA program\n\n
\nOutpatient treatment of substance use problems from a VA addictions program\n\n
\nOutpatient treatment of substance use problems from a non-VA addictions program\n\n
\nSelf-help groups for substance use problems (such as AA or NA)\n\n
\nIndividual meetings with a chaplain in the VA while you were an outpatient\n\n
\nIndividual meetings with a chaplain in the VA while you were an inpatient\n\n
\nIndividual meetings with a member of the clergy outside of the VA\n\n
\nEmergency room visits at any VA or non-VA medical center for PTSD-related problems\n\n
\nInpatient or residential admission for PTSD at a VA Medical Center for any PTSD-related problem (NOT substance use problems)\n\n
\nInpatient or residential admission at a VA Medical Center for substance use problems\n\n
\nThere are a number of people who seem to dislike me very much.\n\n
\nInpatient or residential admission at a VA Medical Center for a suicide attempt or concern about a suicide attempt\n\n
\nInpatient or residential admission at a VA Medical Center for an emotional problem other than PTSD, substance use or suicide attempt\n\n
\nI have nightmares of experiences in the military that really happened.\n\n
\nLately, I have felt like killing myself.\n\n
\nI fall asleep, stay asleep and only awaken when it's time to get up.\n\n
\nMy dreams at night are so real that I waken in a cold sweat and force myself to stay awake.\n\n
\nI feel like I cannot go on.\n\n
\nI do not laugh or cry at the same things other people do.\n\n
\nI enjoy the company of others.\n\n
\nI wonder why I am still alive when others died in the military.\n\n
\n"it is necessity not choice that makes a virtue of abstinence"\nmeans the same as:\n\n
\nI can't help getting into arguments when people disagree with me.\n\n
\nUnexpected noises make me jump.\n\n
\nThere are times when I used alcohol (or other drugs) to help me sleep or make me forget about things that happened while I was in the service.\n\n
\nI lose my cool and explode over minor everyday things.\n\n
\nI have a hard time expressing my feelings, even to the people I care about.\n\n
\nWhen I think of some of the things that I did in the military, I wish I were dead.\n\n
\nRepeated, disturbing memories, thoughts, or images of a stressful military experience?\n\n
\nRepeated, disturbing dreams of a stressful military experience?\n\n
\nSuddenly acting or feeling as if a stressful military experience were happening again (as if you were reliving it)?\n\n
\nFeeling very upset when something reminded you of a stressful military experience?\n\n
\nHaving physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of a stressful military experience?\n\n
\nPeople who shirk on the job must feel very guilty.\n\n
\nAvoiding thinking about or talking about a stressful military experience or avoiding having feelings related to it?\n\n
\nAvoiding activities or situations because they reminded you of a stressful military experience?\n\n
\nTrouble remembering important parts of a stressful military experience?\n\n
\nLoss of interest in activities that you used to enjoy?\n\n
\nFeeling distant or cut off from other people?\n\n
\nFeeling emotionally numb or being unable to have loving feelings for those close to you?\n\n
\nFeeling as if your future somehow will be cut short?\n\n
\nTrouble falling or staying asleep?\n\n
\nFeeling irritable or having angry outbursts?\n\n
\nHaving difficulty concentrating?\n\n
\nIf somebody hits me first; I let him have it.\n\n
\nBeing "superalert" or watchful or on guard?\n\n
\nFeeling jumpy or easily startled?\n\n
\nHow well are you able to cope with military stress reactions so that they don't interfere too greatly with your life?\n\n
\nLittle interest or pleasure in doing things\n\n
\nFeeling down, depressed, or hopeless.\n\n
\nTrouble falling or staying asleep, or sleeping too much.\n\n
\nFeeling tired or having little energy.\n\n
\nPoor appetite or overeating.\n\n
\nFeeling bad about yourself-or that you are a failure or have let yourself or your family down.\n\n
\nTrouble concentrating on things, such as reading the newspaper or watching television.\n\n
\nWhen I am mad, I sometimes slam doors.\n\n
\nMoving or speaking so slowly that other people could have noticed? Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual.\n\n
\nThoughts that you would be better off dead or hurting yourself in some way.\n\n
\nDuring the past month, my desire to make an active suicide attempt.\n\n
\nDuring the past month, I thought of suicide.\n\n
\nDuring the past month, when I thought of suicide.\n\n
\nHave you attempted suicide at any time in the last 4 months?\n\n
\nDo you have immediate access to loaded firearms that don't have trigger locks or other safety features (for example, by the bed, in the car, in the home)?\n\n
\nDuring the past month on average, how many hours of actual sleep did you get per night? (This may be different than the number of hours you spent in bed.) Round to the nearest whole hour.\n\n
\nDuring the past month, how would you rate your sleep quality overall?\n\n
\nDid your use of alcohol in the past 4 months lead to any problems in your life, such as in meeting your responsibilities or in your relationships with other people?\n\n
\nI am always patient with others.\n\n
\nIs the patient alert?\n\n
\nHow many days in the 4 months prior to beginning this program did you drink alcohol at all?\n\n
\nHow many days in the 4 months prior to beginning this program did you drink alcohol to the point where you felt drunk or intoxicated or had 3 or more drinks in one sitting?\n\n
\nI have been unhappy because of my drinking.\n\n
\nI have taken foolish risks when I have been drinking.\n\n
\nMy physical health has been harmed by my drinking.\n\n
\nMy drinking has gotten in the way of my growth as a person.\n\n
\nMy drinking has damaged my social life, popularity, or reputation.\n\n
\nI have spent too much or lost a lot of money because of my drinking.\n\n
\nI have had an automobile accident or injured myself while drinking or while intoxicated.\n\n
\nOccasionally when I am mad at someone I will give him the "silent treatment."\n\n
\nDid your use of drugs, such as marijuana, heroin or cocaine, in the past 4 months lead to any problems in your life, such as in meeting your responsibilities or in your relationships with other \n people?\n\n
\nLevel of education:\n\n
\nHow many days in the past 4 months prior to beginning this program did you use drugs at all?\n\n
\nBecause of my drug use, I have not eaten properly.\n\n
\nI have failed to do what is expected of me because of my drug use.\n\n
\nI have felt guilty or ashamed because of my drug use.\n\n
\nWhen using drugs, I have done impulsive things that I regretted later.\n\n
\nI have had money problems because of my drug use.\n\n
\nMy family has been hurt by my drug use.\n\n
\nA friendship or close relationship has been damaged by my drug use.\n\n
\nWhen I look back on what's happened to me, I can't help feeling mildly resentful.\n\n
\nOverall, how would you rate your health during the past 4 weeks?\n\n
\nDuring the past 4 weeks, how much did physical health problems limit your usual physical activities (such as walking or climbing stairs)?\n\n
\nDuring the past 4 weeks, how much difficulty did you have doing your daily work, both at home and away from home, because of your physical health?\n\n
\nHow much bodily pain have you had during the past 4 weeks?\n\n
\nDuring the past 4 weeks, how much energy did you have?\n\n
\nDuring the past 4 weeks, how much did your physical health or emotional problems limit your usual social activities with family or friends?\n\n
\nDuring the past 4 weeks, how much have you been bothered by emotional problems (such as feeling anxious, depressed, or irritable)?\n\n
\nDuring the past 4 weeks, how much did personal or emotional problems keep you from doing your usual work, school or other daily activities?\n\n
\nHow many days have you experienced medical problems in the past 30 days? (Include both major and minor ailments except temporary alcohol or drug problems. If no problems, enter "0"\n\n
\nHow troubled or bothered have you been by these medical problems in the past 30 days?\n\n
\nThere are a number of people who seem to be jealous of me.\n\n
\nHow important to you now is additional treatment beyond what you have been receiving all along for these medical problems?\n\n
\nOn average, about how many cigarettes a day do you smoke? (1 pack is 20 cigarettes.)\n\n
\nOver the past month, how often have you engaged in regular activities (for example, brisk walking, jogging, bicycling, etc.) long enough to work up a sweat?\n\n
\n5ave you used any health care services for your physical health within the last year?\n\n
\nI find strength and comfort in my religion.\n\n
\nMy religion provides me with satisfying answers to questions about the meaning or purpose of life.\n\n
\nMy whole approach to life is based on my religion.\n\n
\nWhat religion offers me most is comfort in times of trouble and sorrow.\n\n
\nI go to church mainly because I enjoy seeing people I know there.\n\n
\nI feel God's presence.\n\n
\nI demand that people respect my rights.\n\n
\nI feel deep inner peace or harmony.\n\n
\nI feel God's love for me, directly or through others.\n\n
\nI am spiritually touched by the beauty of creation.\n\n
\nHow often do you attend religious services?\n\n
\nHow often do you pray or meditate privately in places other than at a house of worship?\n\n
\nWhat is your employment status?\n\n
\nHow many days did you work for pay during the past 30 days?\n\n
\nDuring the past 4 months, how often have you had friends or relatives over to your home?\n\n
\nAbout how often have you visited with friends or relatives at their homes during the past 4 months?\n\n
\nDuring the past 4 months, about how often did you go out with friends or relatives (for example, meet for coffee, go to a movie, bowl, go to church)?\n\n
\nIt depresses me that I did not do more for my parents.\n\n
\nAbout how often did you have telephone, mail, or computer contact with friends or relatives during the past 4 months?\n\n
\nDid you do any of these during the last 4 months? (Check all that apply)\n\n
\nGot out of the house...\n\n
\nDid an activity for pleasure or fun (for example, going to a movie, going fishing, playing chess)...\n\n
\nDid chores out in the community (for example, shopping, going to bank)...\n\n
\nYour life as a whole; that is, your health, your relationships with other people, and your recreational activities overall?\n\n
\nThe living arrangements where you live?\n\n
\nThe way you spend your free time?\n\n
\nThe amount of time you spend with other people?\n\n
\nThe amount of fun you have?\n\n
\nExtremity Movements\n \nUpper (arms, wrists, hands, fingers).\nInclude movements that are choreic (rapid, objectively purposeless,\nIrregular, spontaneous) or athetoid (slow, irregular, complex,\nserpentine). Do not include tremor (repetitive, regular, rhythmic\nmovements).\n \n\n
\nIf 14 men do a job in ten days, how many more men would the company\nhave to hire in order to get the job done in five days, provided\nthe new men work only half as fast as the original 14 men?\n\n
\nWhoever insults me or my family is asking for a fight.\n\n
\nThe way things are in general between you and your family?\n\n
\nThe amount of friendship in your life?\n\n
\nHow comfortable and well-off you are financially?\n\n
\nYour physical condition?\n\n
\nYour emotional well-being?\n\n
\nHow effective has the care you received from this specialized PTSD program been in helping you achieve your goals for entering treatment?\n\n
\nHow easy or difficult has it been for you to open up about yourself in treatment?\n\n
\nHow satisfied overall are you with the care you received from the specialized PTSD program?\n\n
\nHow satisfied specifically are you with the changes you've made as a result of participating in treatment?\n\n
\nHow satisfied are you specifically with the interactions you had with program staff?\n\n
\nI never play practical jokes.\n\n
\nHow satisfied are you specifically with the waiting time for treatment by this program?\n\n
\nHow satisfied are you specifically with the arrangements to make women comfortable in coming to this program for treatment?\n\n
\nHow likeable have you found your therapist(s) to be personally?\n\n
\nHow much competence and expertise has your therapist(s) shown in treating you?\n\n
\nHow much have you and your therapist(s) agreed on the methods and goals of your treatment?\n\n
\nHow friendly and caring has the staff been toward you?\n\n
\nHow much has your emotional or psychological health improved or not improved since you began treatment in this program?\n\n
\nWhat is your treatment status currently?\n\n
\nChief Complaint:\n\n
\nHistory of Present Illness, or Interval History since last visit\n\n
\nIt makes my blood boil to have somebody make fun of me.\n\n
\nChange in Marital Status:\n\n
\nHighest educational level achieved:\n\n
\nCurrent school or training status:\n\n
\nCurrent employment status:\n\n
\nExperienced head injury since prior evaluation?\n\n
\nDate of most recent TBI since prior evaluation:\n\n
\nBullet\n\n
\nVehicular:\n\n
\nFall:\n\n
\nBlast:\n\n
\nWhen people are bossy, I take my time just to show them.\n\n
\nWhen a high-explosive bomb or IED goes off there is a "blast wave" which is a wave of highly compressed gas that may feel almost like being smashed into a wall. Do you remember experiencing this or \nwere told that you experienced it?\n\n
\nDistance to blast: (Indicate the closest episode)\n\n
\nThis "blast wave" is followed by a wind in which particles of sand, debris, shrapnel, and fragments are moving rapidly. Were you close enough to the blast to be "peppered" or hit by such debris, \nshrapnel, or other items?\n\n
\nDistance to blast: (Indicate the closest episode)\n\n
\nWere you thrown to the ground or against some stationary object, like a wall or vehicle, by the explosion? This is not asking if you "ducked to the ground" to protect yourself.\n\n
\nDistance to blast: (Indicate the closest episode)\n\n
\nDid you experience any of the following injuries as a result of an explosive blast: burns, wounds, broken bones, amputations, breathing toxic fumes, or crush injuries from structures falling onto \nyou?\n\n
\nDistance to blast: (Indicate the closest episode)\n\n
\nType of blast exposures: (Check all that apply)\n\n
\nOther causes of injury: (Were you injured in any other way?)\n\n
\nAlmost every week I see someone I dislike.\n\n
\nDid you lose consciousness immediately after any of these experiences?\n\n
\nWhat was the longest duration of unconsciousness?\n\n
\nDid you have a period of disorientation or confusion immediately following the incident?\n\n
\nWhat was the duration of longest period of alteration of consciousness?\n\n
\nDid you experience a period of memory loss immediately before or after the incident?\n\n
\nWhat was the duration of longest period of memory loss?\n\n
\nDuring this/these experience(s), did an object penetrate your skull/cranium:\n\n
\nFeeling Dizzy:\n\n
\nLoss of balance:\n\n
\nPoor coordination, clumsy:\n\n
\nI sometimes have the feeling that others are laughing at me.\n\n
\nHeadaches:\n\n
\nNausea:\n\n
\nVision problems, blurring, trouble seeing:\n\n
\nSensitivity to light:\n\n
\nHearing difficulty:\n\n
\nSensitivity to noise:\n\n
\nNumbness or tingling in parts of my body:\n\n
\nChange in ability to taste and/or smell:\n\n
\nLoss of appetite or increase appetite:\n\n
\nPoor concentration, can't pay attention:\n\n
\nEven when my anger is aroused, I don't use "strong language."\n\n
\nForgetfulness, can't remember things:\n\n
\nDifficulty making decisions:\n\n
\nSlowed thinking, difficulty getting organized, can't finish things:\n\n
\nFatigue, loss of energy, getting tired easily:\n\n
\nDifficulty falling or staying asleep:\n\n
\nFeeling anxious or tense:\n\n
\nFelling depressed or sad:\n\n
\nIrritability, easily annoyed:\n\n
\nPoor frustration tolerance, feeling easily overwhelmed by things:\n\n
\nOverall, in the last 30 days how much did these difficulties (symptoms?) interfere with your life?\n\n
\nI am concerned about being forgiven for my sins.\n\n
\nIn what areas of your life are you having difficulties because of these symptoms?\n\n
\nIn the last 30 days, have you had any problems with pain?\n\n
\nLocation of pain: (Check all that apply)\n\n
\nOther:\n\n
\nIn the last 30 days, how much did pain interfere with your life?\n\n
\nIn what areas of your life are you having difficulties because of pain?\n\n
\nSince your last evaluation, are your overall symptoms:\n\n
\nAdditional comments regarding current symptoms/functional status:\n\n
\nSystem Review:\n\n
\nPhysical Exam:\n\n
\nPeople who continually pester you are asking for a punch in the nose.\n\n
\nCurrent medications:\n\n
\nProfessional conclusion/assessment:\n\n
\nHas the patient experienced a new TBI since their last diagnosis?\n\n
\nWhat day of the week is it?\n\n
\nFollow up plan: (Check all that apply)\n\n
\nDetails of plan:\n\n
\nDate:\n\n
\nNumber of red shirts:\n\n
\nNumber of blue shirts:\n\n
\nNumber of white shirts:\n\n
\nI sometimes pout when I don't get my own way.\n\n
\nNumber of yellow shirts:\n\n
\nTally of all shirts:\n\n
\nWhat is the year?\n\n
\nWhat state are we in?\n\n
\nHow much did you spend?\n\n
\nHow much do you have left?\n\n
\nPlease name as many animals as you can in one minute.\n\n
\nWhat were the five objects I asked you to remember?\n\n
\n\n\n
\n\n\n
\nThe house of parliament is to the white house, as the\nhouse of representatives is to the:\n\n
\nIf somebody annoys me, I am apt to tell him what I think of him.\n\n
\n\n\n
\nHour markers:\n\n
\nTime:\n\n
\nPlease place an X in the triangle.\n\n
\nWhich figure is the largest?\n\n
\nWhat was the female's name?\n\n
\nWhat work did she do?\n\n
\nWhen did she go back to work?\n\n
\nWhat state did she live in?\n\n
\nFeeling nervous, anxious or on edge\n\n
\nI often feel like a powder keg ready to explode.\n\n
\nNot being able to stop or control worrying\n\n
\nWorrying too much about different things\n\n
\nTrouble relaxing\n\n
\nBeing so restless that it is hard to sit still\n\n
\nBecoming easily annoyed or irritable\n\n
\nFeeling afraid as if something awful might happen\n\n
\nAre you basically satisfied with your life?\n\n
\nHave you dropped many of your activities and interests?\n\n
\nDo you feel that your life is empty?\n\n
\nDo you often get bored?\n\n
\nAlthough I don't show it, I am sometimes eaten up with jealousy.\n\n
\nAre you in good spirits most of the time?\n\n
\nAre you afraid that something bad is going to happen to you?\n\n
\nDo you feel happy most of the time?\n\n
\nDo you often feel helpless?\n\n
\nDo you prefer to stay at home, rather than going out and doing new things?\n\n
\nDo you feel you have more problems with memory than most?\n\n
\nDo you think it is wonderful to be alive now?\n\n
\nDo you feel pretty worthless the way you are now?\n\n
\nDo you feel full of energy?\n\n
\nDo you feel that your situation is hopeless?\n\n
\nMy motto is "never trust strangers."\n\n
\nDo you think that most people are better off than you are?\n\n
\nShopping\n\n
\nBathing: either sponge bath, tub bath or shower.\n\n
\nDressing: gets clothes from closets and drawers, including under-clothes, outer garments and using fasteners (including braces if worn).\n\n
\nToileting: going to the "toilet room" for bowel and urine elimination; cleaning self after elimination and arranging clothes. (May use cane, walker, or wheelchair, and manage bedpan or commode, \nemptying same next morning).\n\n
\nTransfer:\n\n
\nContinence:\n\n
\nFeeding:\n\n
\nToday's date:\n\n
\nOn a scale of 0 to 10, with 0 being no pain at all and 10 being the worst possible pain, how would you rate your pain on the AVERAGE during the LAST WEEK?\n\n
\nWhen people yell at me, I yell back.\n\n
\nDoes your pain interfere with your ability to walk?\n\n
\nDoes your pain interfere with your ability to carry/handle everyday objects such as a bag of groceries or books?\n\n
\nDoes your pain interfere with your ability to climb stairs?\n\n
\nDoes your pain require you to use a cane, walker, wheelchair or other devices?\n\n
\nDoes your pain interfere with your ability to bathe yourself?\n\n
\nDoes your pain interfere with your ability to dress yourself?\n\n
\nDoes your pain interfere with your ability to use the bathroom?\n\n
\nDoes your pain interfere with your ability to manage your personal grooming (for example, combing your hair, brushing your teeth, etc.)?\n\n
\nDoes your pain affect your self-esteem or self-worth?\n\n
\nHow would you rate your physical activity?\n\n
\nI do many things that make me feel remorseful afterward.\n\n
\nHow would you rate your overall energy?\n\n
\nHow would you rate your strength and endurance TODAY?\n\n
\nHow would you rate your feelings of depression TODAY?\n\n
\nHow would you rate your feelings of anxiety TODAY?\n\n
\nHow much do you worry about re-injuring yourself if you are more active?\n\n
\nHow safe do you think it is for you to exercise?\n\n
\nDo you have problems concentrating on things TODAY?\n\n
\nHow often do you feel tense?\n\n
\nThe event you experienced was:\n\n
\nDate of the event:\n\n
\nWhen I really lose my temper, I am capable of slapping someone.\n\n
\nRepeated disturbing MEMORIES, THOUGHTS or IMAGES of the stressful experience?\n\n
\nRepeated disturbing DREAMS of the stressful experience?\n\n
\nSuddenly ACTING or FEELING as if the stressful experience from the past were happening again (as if you were reliving it)?\n\n
\nFeeling VERY UPSET when SOMETHING reminded you of the stressful experience?\n\n
\nHaving PHYSICAL reactions (e.g., heart pounding, trouble breathing, sweating) when SOMETHING REMINDED you of the stressful experience?\n\n
\nAvoiding THINKING ABOUT or TALKING ABOUT the stressful experience from the past or AVOIDING HAVING FEELINGS related to it?\n\n
\nAvoiding ACTIVITIES or SITUATIONS because they REMINDED you of the stressful experience?\n\n
\nTrouble REMEMBERING IMPORTANT PARTS of the stressful experience?\n\n
\nLOSS of INTEREST in activities that you used to enjoy?\n\n
\nFeeling DISTANT or CUT OFF from other people?\n\n
\nSince the age of ten, I have never had a temper tantrum.\n\n
\nFeeling EMOTIONALLY NUMB or being unable to have loving feelings for those close to you?\n\n
\nFeeling as if your FUTURE somehow will be CUT SHORT?\n\n
\nTrouble FALLING or STAYING ASLEEP?\n\n
\nFeeling IRRITABLE or having ANGRY OUTBURSTS?\n\n
\nHaving DIFFICULTY CONCENTRATING?\n\n
\nBeing "SUPERALERT" or watchful or on guard?\n\n
\nFeeling JUMPY or easily startled?\n\n
\nFood Preparation\n\n
\nDate and Time of event:\n\n
\nHousekeeping\n\n
\nWhen I get mad, I say nasty things.\n\n
\nLocation of event:\n\n
\nPatient status at time of event:\n\n
\nHospitalized at:\n\n
\nLaundry\n\n
\nMode of Transportation\n\n
\nResponsibility for own medications\n\n
\nMethod of information:\n\n
\nSource of information:\n\n
\nSpecify "Other":\n\n
\nName and phone of source:\n\n
\nI sometimes carry a chip on my shoulder.\n\n
\nAbility to Handle Finances\n\n
\nStomach pain\n\n
\nBack pain\n\n
\nDid the patient have access to firearms?\n\n
\nBrief description of event:\n\n
\nPatient was receiving treatment in the following area(s) at the time of this event:\n\n
\nName any specialty clinic(s) patient was receiving treatment at time of this event (if none, type "None"):\n\n
\nBrief Plan or Disposition (Check all that apply):\n\n
\nAny other plan or disposition not list above? (If none, type "None")\n\n
\nPlease indicate who your significant other is:\n\n
\nLimpid is most nearly opposite in meaning to:\n\n
\nIf I let people see the way I feel, I'd be considered a hard person to get along with.\n\n
\nSignificant other:\n\n
\nDo you currently live with this person?\n\n
\nRate the level of your pain at the present moment.\n\n
\nIn general, how much does your pain problem interfere with your day to day activities?\n\n
\nAre you retired from work for reasons other than your pain problem?\n\n
\nSince the time you developed a pain problem, how much has your pain changed your ability to work?\n\n
\nHow much has your pain changed the amount of satisfaction or enjoyment you get from participating in social and recreational activities?\n\n
\nHow supportive or helpful is your spouse (significant other) to you in relation to your pain?\n\n
\nRate your overall mood during the PAST WEEK.\n\n
\nOn the average, how severe has your pain been during the LAST WEEK?\n\n
\nI commonly wonder what hidden reason another person may have for doing something nice for me.\n\n
\nHow much has your pain changed your ability to participate in recreational and other social activities?\n\n
\nHow much has your pain changed the amount of satisfaction you get from family-related activities?\n\n
\nHow worried is your spouse (significant other) about you in reaction to your pain problem?\n\n
\nDuring the PAST WEEK, how much control do you feel that you have had over your life?\n\n
\nHow much SUFFERING do you experience because of your pain?\n\n
\nHow much has your pain changed your marriage and other family relationships?\n\n
\nAre you currently working?\n\n
\nHow much has your pain changed the amount of satisfaction or enjoyment you get from work?\n\n
\nHow attentive is your spouse (significant other) to your pain problem?\n\n
\nDuring the PAST WEEK, how much do you feel that you've been able to deal with your problems?\n\n
\nI could not put someone in his place, even if he needed it.\n\n
\nHow much has your pain changed your ability to do household chores?\n\n
\nDuring the PAST WEEK, how irritable have you been?\n\n
\nHow much has your pain changed your friendships with people other than your family?\n\n
\nDuring the PAST WEEK, how tense or anxious have you been?\n\n
\nDo you feel that because of the time you spend with your relative that you do not have enough time for yourself?\n\n
\nIgnores me.\n\n
\nAsks me what he/she can do to help.\n\n
\nReads to me.\n\n
\nExpresses irritation at me.\n\n
\nTakes over my jobs or duties.\n\n
\nFailure gives me a feeling of remorse.\n\n
\nTalks to me about something else to take my mind off the pain.\n\n
\nExpresses frustration with me.\n\n
\nTries to get me to rest.\n\n
\nTries to involve me in some activity.\n\n
\nExpresses anger with me.\n\n
\nGets me some pain medication.\n\n
\nEncourages me to work on a hobby.\n\n
\nGets me something to eat or drink.\n\n
\nTurns on the TV to take my mind off my pain.\n\n
\nWashes dishes.\n\n
\nI get into fights about as often as the next person.\n\n
\nMow the lawn.\n\n
\nGo out to eat.\n\n
\nPlay cards or other games.\n\n
\nGo grocery shopping.\n\n
\nWork in the garden.\n\n
\nGo to a movie.\n\n
\nVisit a friend.\n\n
\nHelp with the house cleaning.\n\n
\nWork on a car.\n\n
\nTake a ride in a car.\n\n
\nI can remember being so angry that I picked up the nearest thing and broke it.\n\n
\nVisit relatives.\n\n
\nPrepare a meal.\n\n
\nWash the car.\n\n
\nTake a trip.\n\n
\nGo to a park or beach.\n\n
\nDo a load of laundry.\n\n
\nWork on a needed house repair.\n\n
\nDo you feel stressed between caring for your relative and trying to meet other responsibilities (work/family)?\n\n
\nDo you feel strained when you are around your relative?\n\n
\nDo you feel uncertain about what to do about your relative?\n\n
\nI often make threats I don't really mean to carry out.\n\n
\nDo you feel that because of the time you spend with your relative that you do not have enough time for yourself?\n\n
\nDo you feel stressed between caring for your relative and trying to meet other responsibilities (work/family)?\n\n
\nDo you feel angry when you are around your relative?\n\n
\nDo you feel that your relative currently affects your relationship with family members or friends in a negative way?\n\n
\nDo you feel strained when you are around your relative?\n\n
\nDo you feel that your health has suffered because of your involvement with your relative?\n\n
\nDo you feel that you do not have as much privacy as you would like because of your relative?\n\n
\nDo you feel that your social life has suffered because you are caring for your relative?\n\n
\nDo you feel that you have lost control of your life since your relatives illness?\n\n
\nDo you feel uncertain about what to do about your relative?\n\n
\nI can't help being a little rude to people I don't like.\n\n
\nDo you feel you should be doing more for your relative?\n\n
\nDo you feel you could do a better job in caring for your relative?\n\n
\nDate of administration:\n\n
\nMethod of administration:\n\n
\nIn the past 30 days, how would you say your physical health has been?\n\n
\nIn the past 30 days, how many nights did you have trouble falling asleep or staying asleep?\n\n
\nIn the past 30 days, how many days have you felt depressed, anxious, angry or very upset throughout most of the day?\n\n
\nIn the past 30 days, how many days did you drink ANY alcohol?\n\n
\nIn the past 30 days, how many days did you have at least 5 drinks (if you are a man) or at least 4 drinks (if you are a woman)? [One drink is considered one shot of hard liquor (1.5 oz.) or 12-ounce \n can/bottle of beer or 5 ounce glass of wine.]\n\n
\nIn the past 30 days, how many days did you use any illegal or street drugs or abuse any prescription medications?\n\n
\nAt times I feel I get a raw deal out of life.\n\n
\nMarijuana (cannabis, pot, weed)?\n\n
\nSedatives and/or Tranquilizers (benzos, Valium, Xanax, Ativan, Ambien, barbs, Phenobarbital, downers, etc.)?\n\n
\nCocaine and/or Crack?\n\n
\nOther Stimulants (amphetamine, methamphetamine, Dexedrine, Ritalin, Adderall, speed, crystal meth, ice, etc.)?\n\n
\nOpiates (Heroin, Morphine, Dilaudid, Demerol, Oxycontin, oxy, codeine (Tylenol 2,3,4), Percocet, Vicodin, Fentanyl, etc.)?\n\n
\nInhalants (glues, adhesives, nail polish remover, paint thinner, etc.)?\n\n
\nOther drugs (steroids, non-prescription sleep and diet pills, Benadryl, Ephedra, other over-the-counter or unknown medications)?\n\n
\nIn the past 30 days, how much were you bothered by cravings or urges to drink alcohol or use drugs?\n\n
\nHow confident are you that you will NOT use alcohol and drugs in the next 30 days?\n\n
\nIn the past 30 days, how many days did you attend self-help meetings like AA or NA to support your recovery?\n\n
\nI used to think that most people told the truth but now I know otherwise.\n\n
\nIn the past 30 days, how many days were you in any situations or with any people that might put you at an increased risk for using alcohol or drugs (i.e., around risky "people, places or things")?\n\n
\nDoes your religion or spirituality help support your recovery?\n\n
\nIn the past 30 days, how many days did you spend much of the time at work, school, or doing volunteer work?\n\n
\nDo you have enough income (from legal sources) to pay for necessities such as housing, transportation, food and clothing for yourself and your dependents?\n\n
\nIn the past 30 days, how much have you been bothered by arguments or problems getting along with any family members or friends?\n\n
\nIn the past 30 days, how many days did you contact or spend time with any family members or friends who are supportive of your recovery?\n\n
\nHow satisfied are you with your progress toward achieving your recovery goals?\n\n
\nPain in your arms, legs, or joints (knees, hips, etc.)\n\n
\nMenstrual cramps or other problems with your periods [Women only]\n\n
\nHeadaches\n\n
\nI feel like I'm up against the world.\n\n
\nI generally cover up my poor opinion of others.\n\n
\nChest pain\n\n
\nDizziness\n\n
\nFainting spells\n\n
\nFeeling your heart pound or race\n\n
\nShortness of breath\n\n
\nPain or problems during sexual intercourse\n\n
\nConstipation, loose bowels, or diarrhea\n\n
\nNausea, gas, or indigestion\n\n
\nFeeling tired or having low energy\n\n
\nI feel out of place in the world because I have a mental illness.\n\n
\nWhen I do wrong, my conscience punishes me severely.\n\n
\nMentally ill people tend to be violent.\n\n
\nPeople discriminate against me because I have a mental illness.\n\n
\nI avoid getting close to people who don't have a mental illness to avoid rejection.\n\n
\nI am embarrassed or ashamed that I have a mental illness.\n\n
\nMentally ill people shouldn't get married.\n\n
\nPeople with mental illness make important contributions to society.\n\n
\nI feel inferior to others who don't have a mental illness.\n\n
\nI don't socialize as much as I used to because my mental illness might make me look or behave "weird."\n\n
\nPeople with mental illness cannot live a good, rewarding life.\n\n
\nI don't talk about myself much because I don't want to burden others with my mental illness.\n\n
\nIf I have to resort to physical violence to defend my rights, I will.\n\n
\nNegative stereotypes about mental illness keep me isolated from the "normal" world.\n\n
\nBeing around people who don't have a mental illness makes me feel out of place or inadequate.\n\n
\nI feel comfortable being seen in public with an obviously mentally ill person.\n\n
\nPeople often patronize me, or treat me like a child, just because I have a mental illness.\n\n
\nI am disappointed in myself for having a mental illness.\n\n
\nHaving a mental illness has spoiled my life.\n\n
\nPeople can tell that I have a mental illness by the way I look.\n\n
\nBecause I have a mental illness, I need others to make most decisions for me.\n\n
\nI stay away from social situations in order to protect my family or friends from embarrassment.\n\n
\nPeople without mental illness could not possibly understand me.\n\n
\nIf someone doesn't treat me right, I don't let it annoy me.\n\n
\nPeople ignore me or take me less seriously just because I have a mental illness.\n\n
\nI can't contribute anything to society because I have a mental illness.\n\n
\nLiving with mental illness has made me a tough survivor.\n\n
\nNobody would be interested in getting close to me because I have a mental illness.\n\n
\nIn general, I am able to live my life the way I want to.\n\n
\nI can have a good, fulfilling life, despite my mental illness.\n\n
\nOthers think that I can't achieve much in life because I have a mental illness.\n\n
\nStereotypes about the mentally ill apply to me.\n\n
\nPlease remember these five objects. I will ask you what they are later. Apple Pen Tie House Car\n\n
\nIs there any indication the Veteran engaged in self-directed violent behavior?\n\n
\nI have no enemies who really wish to harm me.\n\n
\nIs or was there evidence of Suicidal Intent?\n\n
\nDid the behavior involve any injury?\n\n
\nSelect the most appropriate SDV behavior from this list:\n\n
\nSelect the most appropriate SDV behavior from this list:\n\n
\nVeteran status following the event:\n\n
\nFamily and other supports available at time of the event:\n\n
\nOther support:\n\n
\nTreatment plan changes implemented due to the event:\n\n
\nInpatient Unit at time of event:\n\n
\nInpatient status at time of event:\n\n
\nWhen arguing, I tend to raise my voice.\n\n
\nPrimary Care Provider:\n\n
\nPrimary provider:\n\n
\nCase Manager / Therapist:\n\n
\nProvider prescribing psychiatric medications:\n\n
\nStaff combo box:\n\n
\nStaff combo box:\n\n
\nDescribe/Other:\n\n
\nManaging your day-to-day life?\n\n
\nCoping with problems in your life?\n\n
\nConcentrating?\n\n
\nI often feel that I have not lived the right kind of life.\n\n
\nGet along with people in your family?\n\n
\nGet along with people outside your family?\n\n
\nGet along well in social situations?\n\n
\nFeel close to another person?\n\n
\nFeel like you had someone to turn to if you needed help?\n\n
\nFeel confident in yourself?\n\n
\nFeel sad or depressed?\n\n
\nThink about ending your life?\n\n
\nFeel nervous?\n\n
\nHave thoughts racing through your head?\n\n
\nI have known people who pushed me so far that we came to blows.\n\n
\nThink you had special powers?\n\n
\nHear voices or see things?\n\n
\nThink people were watching you?\n\n
\nThink people were against you?\n\n
\nHave mood swings?\n\n
\nFeel short-tempered?\n\n
\nThink about hurting yourself?\n\n
\nDid you have an urge to drink alcohol or take street drugs?\n\n
\nDid anyone talk to you about your drinking or drug use?\n\n
\nDid you try to hide your drinking or drug use?\n\n
\nI don't let a lot of unimportant things irritate me.\n\n
\nDid you have problems from your drinking or drug use?\n\n
\nIf my condition worsens, it is my own behavior which determines how soon I will feel better again.\n\n
\nAs to my condition, what will be will be.\n\n
\nIf I see my doctor regularly, I am less likely to have problems with my condition.\n\n
\nMost things that affect my condition happen to me by chance.\n\n
\nWhenever my condition worsens, I should consult a medically trained professional.\n\n
\nI am directly responsible for my condition getting better or worse.\n\n
\nOther people play a big role in whether my condition improves, stays the same, or gets worse.\n\n
\nWhatever goes wrong with my condition is my own fault.\n\n
\nLuck plays a big part in determining how my condition improves.\n\n
\nI seldom feel that people are trying to anger or insult me.\n\n
\nIn order for my condition to improve, it is up to other people to see that the right things happen.\n\n
\nWhatever improvement occurs with my condition is largely a matter of good fortune.\n\n
\nThe main thing which affects my condition is what I myself do.\n\n
\nI deserve the credit when my condition improves and the blame when it gets worse.\n\n
\nFollowing doctor's orders to the letter is the best way to keep my condition from getting any worse.\n\n
\nIf my condition worsens, it's a matter of fate.\n\n
\nIf I am lucky, my condition will get better.\n\n
\nIf my condition takes a turn for the worse, it is because I have not been taking proper care of myself.\n\n
\nThe type of help I receive from other people determines how soon my condition improves.\n\n
\nThe event you experienced was:\n\n
\nI'm no good.\n\n
\nLately, I have been kind of grouchy.\n\n
\nTrouble sleeping\n\n
\nRepeated disturbing MEMORIES, THOUGHTS or IMAGES of the stressful experience?\n\n
\nRepeated disturbing DREAMS of the stressful experience?\n\n
\nSuddenly ACTING or FEELING as if the stressful experience from the past were happening again (as if you were reliving it)?\n\n
\nFeeling VERY UPSET when SOMETHING reminded you of the stressful experience?\n\n
\nHaving PHYSICAL reactions (e.g. heart pounding, trouble breathing, sweating) when SOMETHING REMINDED you of the stressful experience?\n\n
\nAvoiding THINKING ABOUT or TALKING ABOUT the stressful experience from the past or AVOIDING HAVING FEELINGS related to it?\n\n
\nAvoiding ACTIVITIES or SITUATIONS because they REMINDED you of the stressful experience?\n\n
\nTrouble REMEMBERING IMPORTANT PARTS of the stressful experience?\n\n
\nLOSS OF INTEREST in activities that you used to enjoy?\n\n
\nI would rather concede a point than get into an argument about it.\n\n
\nFeeling DISTANT or CUT OFF from other people?\n\n
\nFeeling EMOTIONALLY NUMB or being unable to have loving feelings for those close to you?\n\n
\nFeeling as if your FUTURE somehow will be CUT SHORT?\n\n
\nTrouble FALLING or STAYING ASLEEP?\n\n
\nFeeling IRRITABLE or having ANGRY OUTBURSTS?\n\n
\nHaving DIFFICULTY CONCENTRATING?\n\n
\nBeing "SUPERALERT" or watchful or on guard?\n\n
\nFeeling JUMPY or easily startled?\n\n
\nHow difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?\n\n
\nDuring the last two weeks have you had thoughts that you would be better off dead, or of hurting yourself in some way?\n\n
\nI sometimes show my anger by banging on the table.\n\n
\nHow often have you had these thoughts?\n\n
\nBathing:\n\n
\nDressing:\n\n
\nToileting:\n\n
\nTransferring:\n\n
\nContinence:\n\n
\nFeeding:\n\n
\nSensory perception -- ability to respond meaningfully to pressure-related discomfort\n\n
\nMoisture -- degree to which skin is exposed to moisture\n\n
\nActivity -- ability to change and control body position\n\n
\nHave you ever felt you should cut down on your drinking?\n \n\n
\nMobility -- ability to change and control body position\n\n
\nNutrition -- usual food intake patterns\n\n
\nFriction and shear\n\n
\nWhen did the event occur:\n\n
\nAs a result of these sessions I am clearer as to how I might be able to change.\n\n
\nWhat I am doing in therapy gives me new ways of looking at my problem.\n\n
\nI believe my therapist likes me.\n\n
\nMy therapist and I collaborate on setting goals for my therapy.\n\n
\nMy therapist and I respect each other.\n\n
\nMy therapist and I are working towards mutually agreed upon goals.\n\n
\nHave people annoyed you by criticizing your drinking?\n \n\n
\nI feel that my therapist appreciates me.\n\n
\nMy therapist and I agree on what is important for me to work on.\n\n
\nI feel my therapist cares about me even when I do things that he/she does not approve of.\n\n
\nI feel that the things I do in therapy will help me to accomplish the changes that I want.\n\n
\nMy therapist and I have established a good understanding of the kind of changes that|would be good for me.\n\n
\nI believe the way we are working with my problem is correct.\n\n
\nLast Pain Score:\n\n
\nPast 10 clinic visits:\n\n
\nPrimary Care Provider:\n\n
\nActive Problem List:\n\n
\nHave you ever felt bad or guilty about your drinking?\n \n\n
\nIt's OK if I remember something unpleasant.\n\n
\nMy painful experiences and memories make it difficult for me to live a life that I would value.\n\n
\nI am afraid of my feelings.\n\n
\nConfusion/Disorientation/Impulsivity\n\n
\nDepression\n\n
\nAltered elimination\n\n
\nDizziness/vertigo\n\n
\nGender\n\n
\nAny prescribed antiepileptics\n\n
\nAny prescribed benzodiazepines\n\n
\nHave you ever had a drink first thing in the morning to steady your nerves\nor to get rid of a hangover (an eye opener)?\n \n\n
\nGet-up-go Test Item #2: "Rising from chair"\n\n
\nI worry about not being able to control my worries and feelings.\n\n
\nMy painful memories prevent me from having a fulfilling life.\n\n
\nI am in control of my life.\n\n
\nEmotions cause problems in my life.\n\n
\nIt seems like most people are handling their lives better than I am.\n\n
\nWorries get in the way of my success.\n\n
\nMy thoughts and feelings do not get in the way of how I want to live my life.\n\n
\nWhen I'm walking, I deliberately notice the sensations of my body moving.\n\n
\nI'm good at finding words to describe my feelings.\n\n
\nI feel just as energetic as always\n\n
\nI criticize myself for having irrational or inappropriate emotions.\n\n
\nI perceive my feelings and emotions without having to react to them.\n\n
\nWhen I do things, my mind wanders off and I'm easily distracted.\n\n
\nWhen I take a shower or bath, I stay alert to the sensations of water on my body.\n\n
\nI can easily put my beliefs, opinions, and expectations into words.\n\n
\nI don't pay attention to what I'm doing because I'm daydreaming, worrying, or otherwise distracted.\n\n
\nI watch my feelings without getting lost in them.\n\n
\nI tell myself I shouldn't be feeling the way I'm feeling.\n\n
\nI notice how foods and drinks affect my thoughts, bodily sensations, and emotions.\n\n
\nIt's hard for me to find the words to describe what I'm thinking.\n\n
\nI am losing weight\n\n
\nI am easily distracted.\n\n
\nI believe some of my thoughts are abnormal or bad and I shouldn't think that way.\n\n
\nI pay attention to sensations, such as the wind in my hair or sun on my face.\n\n
\nI have trouble thinking of the right words to express how I feel about things.\n\n
\nI make judgments about whether my thoughts are good or bad.\n\n
\nI find it difficult to stay focused on what's happening in the present.\n\n
\nWhen I have distressing thoughts or images, I "step back" and am aware of the thought or image without getting taken over by it.\n\n
\nI pay attention to sounds, such as clocks ticking, birds chirping, or cars passing.\n\n
\nIn difficult situations, I can pause without immediately reacting.\n\n
\nWhen I have a sensation in my body, it's difficult for me to describe it because I can't find the right words.\n\n
\nI have dropped many of my interests and activities\n\n
\nIt seems I am "running on automatic" without much awareness of what I'm doing.\n\n
\nWhen I have distressing thoughts or images, I feel calm soon after.\n\n
\nI tell myself that I shouldn't be thinking the way I'm thinking.\n\n
\nI notice the smells and aromas of things.\n\n
\nEven when I'm feeling terribly upset, I can find a way to put it into words.\n\n
\nI rush through activities without being really attentive to them.\n\n
\nWhen I have distressing thoughts or images I am able just to notice them without reacting.\n\n
\nI think some of my emotions are bad or inappropriate and I shouldn't feel them.\n\n
\nI notice visual elements in art or nature, such as colors, shapes, textures, or patterns of light and shadow.\n\n
\nMy natural tendency is to put my experiences into words.\n\n
\nWhy can't I ever succeed?\n\n
\nSince my illness I have completely lost interest in sex\n\n
\nWhen I have distressing thoughts or images, I just notice them and let them go.\n\n
\nI do jobs or tasks automatically without being aware of what I'm doing.\n\n
\nWhen I have distressing thoughts or images, I judge myself as good or bad, depending what the thought/image is about.\n\n
\nI pay attention to how my emotions affect my thoughts and behavior.\n\n
\nI can usually describe how I feel at the moment in considerable detail.\n\n
\nI find myself doing things without paying attention.\n\n
\nI disapprove of myself when I have irrational ideas.\n\n
\nI worry a lot of the time.\n\n
\nI find it difficult to make a decision.\n\n
\nI often feel jumpy.\n\n
\nI am especially concerned about how my body is functioning\n\n
\nI find it hard to relax.\n\n
\nI often cannot enjoy things because of my worries.\n\n
\nLittle things bother me a lot.\n\n
\nI often feel like I have butterflies in my stomach.\n\n
\nI think of myself as a worrier.\n\n
\nI can't help worrying about even trivial things.\n\n
\nI often feel nervous.\n\n
\nMy own thoughts often make me anxious.\n\n
\nI get an upset stomach due to my worrying.\n\n
\nI think of myself as a nervous person.\n\n
\nIt must be obvious that I am disturbed and agitated\n\n
\nI always anticipate the worst will happen.\n\n
\nI often feel shaky inside.\n\n
\nI think that my worries interfere with my life.\n\n
\nMy worries often overwhelm me.\n\n
\nI sometimes feel a great knot in my stomach.\n\n
\nI miss out on things because I worry too much.\n\n
\nI often feel upset.\n\n
\nWhat is the date? (Answer must be exact.)\n\n
\nPlease draw a clock on the paper provided. Mark in all the numbers to indicate the hours of a clock (Correct: the numbers 12, 3, 6, and 9 should be in the correct quadrants of the circle and the \nother numbers should be approximately correctly placed.)\n\n
\nPlease mark in hands to show 10 minutes past eleven o'clock, 11:10. (Correct: the hands should be pointing to the 11 and the 2, but do not penalize if the respondent fails to distinguish the long and \nshort hands.)\n\n
\nI am still able to carry on doing the work I am supposed to do\n\n
\nCan you tell me something that happened in the news recently? (Correct: Must be in the last week. Extensive details are not required but a general answer without details, e.g., war, lots of rain, after \nprodding, is incorrect.)\n\n
\nJohn\n\n
\nBrown\n\n
\n\n\n
\nWest (Street)\n\n
\nKensington\n\n
\nClock Drawing\n\n
\nRecall of FIRST WORD\n\n
\nRecall of SECOND WORD\n\n
\nRecall of THIRD WORD\n\n
\nI can concentrate easily when reading the papers\n\n
\nAlternating Trail Making. Correct Pattern: 1-A- 2- B- 3- C- 4- D- 5- E, without drawing any lines that cross. Any error that is not immediately self-corrected is scored incorrect.\n\n
\nCube-Visuoconstructional Skills. Correct: All must be present: three-dimensional, all lines are drawn, no line is added, lines are relatively parallel and their length is similar.\n\n
\nClock face must be a circle with only minor distortion acceptable (e.g., slight imperfection on closing the circle).\n\n
\nAll clock numbers must be present with no additional numbers; numbers must be in the correct order and placed in the approximate quadrants on the clock face; Roman numerals are acceptable; numbers \ncan be placed outside the circle contour.\n\n\n
\nThere must be two hands jointly indicating the correct time; the hour hand must be clearly shorter than the minute hand; hands must be centered within the clock face with their junction close to the \n clock center.\n\n\n
\nLion\n\n
\nRhinoceros or rhino\n\n
\nCamel or dromedary\n\n
\nForward Digit Span.\n\n
\nBackward Digit Span. Correct response for the backwards trial is 2-4-7.\n\n
\nGetting to sleep takes me more than half an hour\n\n
\nVigilance. Correct when there is zero to one errors (an error is a tap on a wrong letter or a failure to tap on letter A).\n\n
\nSerial 7s starting at 100. Continue for five responses.\n\n
\nSentence repetition. I only know that John is the one to help today.\n\n
\nSentence repetition. The cat always hid under the couch when dogs were in the room.\n\n
\nWords beginning with the letter F.\n\n
\nSimilarity between TRAIN - BICYCLE.\n\n
\nSimilarity between WATCH - RULER.\n\n
\nRecall FACE\n\n
\nRecall VELVET.\n\n
\nRecall CHURCH.\n\n
\nI am restless and fidgety\n\n
\nRecall DAISY.\n\n
\nRecall RED.\n\n
\nToday's date,\n\n
\nCurrent month\n\n
\nCurrent year\n\n
\nDay of the week\n\n
\nWhat place is this?\n\n
\nWhat city are we in?\n\n
\nYears of formal education:\n\n
\nWhat is your name?\n\n
\nI wake up much earlier than I need to in the morning\n\n
\nWhat is your address?\n\n
\nWhat building are we in now?\n\n
\nIn what city are we now located?\n\n
\nWhat state are we in now?\n\n
\nWhat is today's date?\n\n
\nWhat month is it?\n\n
\nWhat year is it?\n\n
\nDigit Span: 2-9-6-8-3\n\n
\nDigit Span: 5-7-1-9-4-6\n\n
\nDigit Span: 2-1-5-9-3-6-2\n\n
\nDying is the best solution for me\n\n
\nLearn these words: APPLE, MR. JOHNSON, CHARITY, TUNNEL. How many trials were needed to learn all, some or none of the words?\n\n
\nWhat is 5 times 13?\n\n
\nWhat is 65 minus 7?\n\n
\nWhat is 58 divided by 2?\n\n
\nWhat is 29 plus 11?\n\n
\nHow are ORANGE and BANANA alike?\n\n
\nHow are DOG and HORSE alike?\n\n
\nHow are TABLE and BOOKCASE alike?\n\n
\nClock face is circular, and numbers are correctly placed.\n\n
\nThe time is correctly drawn.\n\n
\nI have a lot of trouble with dizzy and faint feelings\n\n
\nCopy the line drawing of a three dimensional cube (Necker's cube). The subject's drawing is complete and correct.\n\n
\nWho is the current president of the United States?\n\n
\nWho was the first president of the United States?\n\n
\nDefine an ISLAND.\n\n
\nHow many weeks are there in a year?\n\n
\nRecall APPLE\n\n
\nRecall MR. JOHNSON\n\n
\nRecall CHARITY\n\n
\nRecall TUNNEL\n\n
\nHow many words were learned?\n\n
\nNo one understands me.\n\n
\nI am being punished for something bad in my past\n\n
\nIn general, would you say your health is:\n\n
\nModerate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf?\n\n
\nClimbing several flights of stairs?\n\n
\nAccomplished less than you would like.\n\n
\nWere limited in the kind of work or other activities.\n\n
\nAccomplished less than you would like.\n\n
\nDidn't do work or other activities as carefully as usual.\n\n
\nDuring the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and house work)?\n\n
\nHave you felt calm and peaceful?\n\n
\nDid you have a lot of energy?\n\n
\nMy sexual interest is the same as before I got sick\n\n
\nHave you felt downhearted and blue?\n\n
\nDuring the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?\n\n
\nCompared to one year ago, how would you rate your physical health in general now?\n\n
\nCompared to one year ago, how would you rate your emotional problems (such as feeling anxious, depressed or irritable) now?\n\n
\nAlternating Trail Making. Correct Pattern: 1-A- 2- B- 3- C- 4- D- 5- E, without drawing any lines that cross. Any error that is not immediately self-corrected is scored incorrect.\n\n
\nRectangle-Visuoconstructional Skills. Correct: All must be present: three-dimensional, all lines are drawn, no line is added, lines are relatively parallel and their length is correct.\n\n
\nClock face must be a circle with only minor distortion acceptable (e.g., slight imperfection on closing the circle).\n\n
\nAll clock numbers must be present with no additional numbers; numbers must be in the correct order and placed in the approximate quadrants on the clock face; Roman numerals are acceptable; numbers \ncan be placed outside the circle contour.\n\n\n
\nThere must be two hands jointly indicating the correct time; the hour hand must be clearly shorter than the minute hand; hands must be centered within the clock face with their junction close to the \nclock center.\n\n\n
\nGiraffe\n\n
\nI am miserable or often feel like crying\n\n
\nBear\n\n
\nHippopotamus\n\n
\nForward Digit Span.\n\n
\nBackward Digit Span. Correct response for the backwards trial is 2-5-8.\n\n
\nVigilance. Correct when there is zero to one errors (an error is a tap on a wrong letter or a failure to tap on letter A).\n\n
\nSerial 7s starting at 90. Continue for five responses.\n\n
\nSentence repetition. A bird can fly into closed windows when it's dark and windy.\n\n
\nSentence repetition. The caring grandmother sent groceries over a week ago.\n\n
\nWords beginning with the letter S.\n\n
\nHave had nightmares about it or thought about it when you did not want to?\n\n
\nI often wish I were dead\n\n
\nSimilarity between DIAMOND - RUBY.\n\n
\nRecall TRUCK\n\n
\nRecall BANANA.\n\n
\nRecall VIOLIN.\n\n
\nRecall DESK.\n\n
\nRecall GREEN.\n\n
\nToday's date,\n\n
\nCurrent month\n\n
\nCurrent year\n\n
\nDay of the week\n\n
\nI am having trouble with indigestion\n\n
\nWhat place is this?\n\n
\nWhat city are we in?\n\n
\nYears of formal education:\n\n
\nSimilarity between CANNON - RIFLE.\n\n
\nAlternating Trail Making. Correct Pattern: 1-A- 2- B- 3- C- 4- D- 5- E, without drawing any lines that cross. Any error that is not immediately self-corrected is scored incorrect.\n\n
\nCylinder-Visuoconstructional Skills. Correct: All must be present: three-dimensional, all lines are drawn, no line is added, lines are relatively parallel and their length is similar.\n\n
\nClock face must be a circle with only minor distortion acceptable (e.g., slight imperfection on closing the circle).\n\n
\nAll clock numbers must be present with no additional numbers; numbers must be in the correct order and placed in the approximate quadrants on the clock face; Roman numerals are acceptable; numbers \ncan be placed outside the circle contour.\n\n\n
\nThere must be two hands jointly indicating the correct time; the hour hand must be clearly shorter than the minute hand; hands must be centered within the clock face with their junction close to the \nclock center.\n\n\n
\nDonkey\n\n
\nI wake up often in the middle of the night\n\n
\nPig\n\n
\nKangaroo\n\n
\nForward Digit Span.\n\n
\nBackward Digit Span. Correct response for the backwards trial is 4-7-1.\n\n
\nVigilance. Correct when there is zero to one errors (an error is a tap on a wrong letter or a failure to tap on letter A).\n\n
\nSerial 7s starting at 80. Continue for five responses.\n\n
\nSentence repetition. She heard his lawyer was the one to sue after the accident.\n\n
\nSentence repetition. The little girls who were given too much candy got stomach aches.\n\n
\nWords beginning with the letter B.\n\n
\nSimilarity between EYE - EAR.\n\n
\nI feel worthless and ashamed about myself\n\n
\nSimilarity between TRUMPET - PIANO.\n\n
\nRecall TRAIN\n\n
\nRecall EGG.\n\n
\nRecall HAT.\n\n
\nRecall CHAIR.\n\n
\nRecall BLUE.\n\n
\nToday's date,\n\n
\nCurrent month\n\n
\nCurrent year\n\n
\nDay of the week\n\n
\nI am so slowed down that I need help with bathing and dressing\n\n
\nWhat place is this?\n\n
\nWhat city are we in?\n\n
\nYears of formal education:\n\n
\nBowels (preceding week):\n\n
\nBladder (preceding week):\n\n
\nGrooming (preceding 24 - 48 hours):\n\n
\nToilet use:\n\n
\nFeeding:\n\n
\nTransfer:\n\n
\nMobility:\n\n
\nI take longer than usual to fall asleep at night\n\n
\nDressing:\n\n
\nStairs:\n\n
\nBathing:\n\n
\nConcentrating on doing something for ten minutes?\n\n
\nRemembering to do important things?\n\n
\nAnalyzing and finding solutions to problems in day-to-day life?\n\n
\nLearning a new task, for example, learning how to get to a new place?\n\n
\nGenerally understanding what people say?\n\n
\nStarting and maintaining a conversation?\n\n
\nStanding for long periods such as 30 minutes?\n\n
\nMuch of the time I am very afraid but don't know the reason\n\n
\nStanding up from sitting down?\n\n
\nMoving around inside your home?\n\n
\nGetting out of your home?\n\n
\nWalking a long distance such as a kilometer [or equivalent]?\n\n
\nWashing your whole body?\n\n
\nGetting dressed?\n\n
\nEating?\n\n
\nStaying by yourself for a few days?\n\n
\nDealing with people you do not know?\n\n
\nMaintaining a friendship?\n\n
\nI've let people down.\n\n
\nThings which I regret about my life are bothering me\n\n
\nGetting along with people who are close to you?\n\n
\nMaking new friends?\n\n
\nSexual activities?\n\n
\nTaking care of your household responsibilities?\n\n
\nDoing most important household tasks well?\n\n
\nGetting all the household work done that you needed to do?\n\n
\nGetting your household work done as quickly as needed?\n\n
\nDo you work (paid, non-paid, self-employed) or go to school?\n\n
\nYour day-to-day work/school?\n\n
\nDoing your most important work/school tasks well?\n\n
\nI get pleasure and satisfaction from what I do\n\n
\nGetting all the work done that you need to do?\n\n
\nGetting your work done as quickly as needed?\n\n
\nHow much of a problem did you have in joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?\n\n
\nHow much of a problem did you have because of barriers or hindrances in the world around you?\n\n
\nHow much of a problem did you have living with dignity because of the attitudes and actions of others?\n\n
\nHow much time did you spend on your health condition, or its consequences?\n\n
\nHow much have you been emotionally affected by your health condition?\n\n
\nHow much has your health been a drain on the financial resources of you or your family?\n\n
\nHow much of a problem did your family have because of your health problems?\n\n
\nHow much of a problem did you have in doing things by yourself for relaxation or pleasure?\n\n
\nAll I need is a good rest to be perfectly well again\n\n
\nOverall, in the past 30 days, how many days were these difficulties present?\n\n
\nIn the past 30 days, for how many days were you totally unable to carry out your usual activities or work because of any health condition?\n\n
\nIn the past 30 days, not counting the days that you were totally unable, for how many days did you cut back or reduce your usual activities or work because of any health condition?\n\n
\nI am not a worrier.\n\n
\nI find it easy to smile and be outgoing with strangers.\n\n
\nI have a very active imagination.\n\n
\nOften, people aren't as nice as they seem to be.\n\n
\nI am efficient and effective at my work.\n\n
\nI often get angry at the way people treat me.\n\n
\nI prefer jobs that let me work alone without being bothered by other people.\n\n
\nMy sleep is restless and disturbed\n\n
\nI'm not really interested in the arts.\n\n
\nI'm not crafty or sly.\n\n
\nI don't mind a little clutter in my room.\n\n
\nI rarely feel lonely or blue.\n\n
\nI am dominant, forceful, and assertive.\n\n
\nI experience a wide range of emotions or feelings.\n\n
\nI'm not known for my generosity.\n\n
\nI try to go to work or school even when I'm not feeling well.\n\n
\nWhen I'm around people, I worry that I'll make a fool of myself.\n\n
\nI have a laid-back style in work and play.\n\n
\nMy mind is as fast and alert as always\n\n
\nI'm pretty set in my ways.\n\n
\nWhen I've been insulted, I just try to forgive and forget.\n\n
\nI don't feel like I'm driven to get ahead.\n\n
\nI seldom give in to my impulses.\n\n
\nI like to be where the action is.\n\n
\nI often enjoy playing with theories or abstract ideas.\n\n
\nI don't mind bragging about my talents and accomplishments.\n\n
\nI'm pretty good about pacing myself so as to get things done on time.\n\n
\nI often feel helpless and want someone else to solve my problems.\n\n
\nI have never literally jumped for joy.\n\n
\nI feel that life is still worth living\n\n
\nI believe we should look to our religious authorities for decisions on moral issues.\n\n
\nWhen making laws and social policies, we need to think about who might be hurt.\n\n
\nOver the years I've done some pretty stupid things.\n\n
\nI am easily frightened.\n\n
\nI don't get much pleasure from chatting with people.\n\n
\nI try to keep all my thoughts directed along realistic lines and avoid flights of fancy.\n\n
\nI believe that most people are basically well-intentioned.\n\n
\nI sometimes act thoughtlessly.\n\n
\nI'm an even-tempered person.\n\n
\nI like to have a lot of people around me.\n\n
\nMy voice is dull and lifeless\n\n
\nI am sometimes completely absorbed in music I am listening to.\n\n
\nIf necessary, I am willing to manipulate people to get what I want.\n\n
\nI keep my belongings neat and clean.\n\n
\nSometimes I feel completely worthless.\n\n
\nI don't find it easy to take charge of a situation.\n\n
\nI rarely experience strong emotions.\n\n
\nI go out of my way to help others if I can.\n\n
\nSometimes I'm not as dependable or reliable as I should be.\n\n
\nI feel comfortable in the presence of my teachers or bosses.\n\n
\nMy life is fast-paced.\n\n
\nI feel irritable or jittery\n\n
\nI believe variety is the spice of life.\n\n
\nIf someone starts a fight, I'm ready to fight back.\n\n
\nI strive to achieve all I can.\n\n
\nI have trouble resisting my cravings.\n\n
\nI wouldn't enjoy vacationing in Las Vegas.\n\n
\nI find philosophical arguments boring.\n\n
\nI'd rather not talk about myself and my achievements.\n\n
\nI have trouble making myself do what I should.\n\n
\nI'm pretty stable emotionally.\n\n
\nI have felt overpowering joy.\n\n
\nI feel in good spirits\n\n
\nI believe that laws and social policies should change to reflect the needs of a changing world.\n\n
\nI have no sympathy for beggars.\n\n
\nI rarely make hasty decisions.\n\n
\nI rarely feel fearful or anxious.\n\n
\nI have strong emotional attachments to my friends.\n\n
\nI enjoy concentrating on a fantasy or daydream and exploring all its possibilities, letting it grow and develop.\n\n
\nI believe that most people will take advantage of you if you let them.\n\n
\nI keep myself informed and usually make intelligent decisions.\n\n
\nI am known as hot-blooded and quick-tempered.\n\n
\nI usually prefer to do things alone.\n\n
\nMy heart sometimes beats faster than usual\n\n
\nPoetry has little or no effect on me.\n\n
\nI couldn't deceive anyone even if I wanted to.\n\n
\nI'm not a very orderly or methodical person.\n\n
\nI am seldom sad or depressed.\n\n
\nI have often been a leader of groups I have belonged to.\n\n
\nOdd things - like certain scents or the names of distant places - can evoke strong moods in me.\n\n
\nSome people think of me as cold and calculating.\n\n
\nI pay my debts promptly and in full.\n\n
\nI often feel that I am not as good as others.\n\n
\nI'm not as quick and lively as other people.\n\n
\nI don't think I can go on.\n\n
\nI think my case is hopeless\n\n
\nOn a vacation, I prefer going back to a tried and true spot.\n\n
\nI hesitate to express my anger even when its justified.\n\n
\nWhen I start a self-improvement program, I usually let it slide after a few days.\n\n
\nI'm always in control of myself.\n\n
\nI love the excitement of roller coasters.\n\n
\nI enjoy working on "mind-twister"-type puzzles.\n\n
\nI have a very high opinion of myself.\n\n
\nOnce I start a project, I almost always finish it.\n\n
\nWhen I'm under a great deal of stress, sometimes I feel like I'm going to pieces.\n\n
\nI rarely use words like "fantastic!" or "sensational!" to describe my experiences.\n\n
\nI wake up before my usual time in the morning\n\n
\nI think that if people don't know what they believe in by the time they're 25, there's something wrong with them.\n\n
\nWe can never do too much for the poor and elderly.\n\n
\nI often do things on the spur of the moment.\n\n
\nI often worry about things that might go wrong.\n\n
\nMany people think of me as somewhat cold and distant.\n\n
\nI would have difficulty just letting my mind wander without control or guidance.\n\n
\nI tend to assume the best about people.\n\n
\nI don't seem to be completely successful at anything.\n\n
\nIt takes a lot to get me mad.\n\n
\nI enjoy parties with lots of people.\n\n
\nI still enjoy my meals as much as usual\n\n
\nSometimes when I am reading poetry or looking at a work of art, I feel a chill or wave of excitement.\n\n
\nAt times I bully or flatter people into doing what I want them to.\n\n
\nI like to keep everything in its place so I know just where it is.\n\n
\nToo often, when things go wrong, I get discouraged and feel like giving up.\n\n
\nIn meetings, I usually let others do the talking.\n\n
\nI seldom pay much attention to my feelings of the moment.\n\n
\nI generally try to be thoughtful and considerate.\n\n
\nI ignore a lot of silly little rules.\n\n
\nIt doesn't embarrass me too much if people ridicule and tease me.\n\n
\nI am a very active person.\n\n
\nI have to keep pacing around most of the time\n\n
\nI often try new and foreign foods.\n\n
\nI'm hard-headed and stubborn.\n\n
\nI work hard to accomplish my goals.\n\n
\nI sometimes eat myself sick.\n\n
\nI tend to avoid movies that are shocking or scary.\n\n
\nI have little interest in speculating on the nature of the universe or the human condition.\n\n
\nI feel that I am no better than others, no matter what their condition.\n\n
\nThere are so many little jobs that need to be done that I sometimes just ignore them all.\n\n
\nI keep a cool head in emergencies.\n\n
\nI am a cheerful, high-spirited person.\n\n
\nI am terrified and near panic\n\n
\nI consider myself broad-minded and tolerant of other people's lifestyles.\n\n
\nI don't worry much about the homeless.\n\n
\nI always consider the consequences before I take action.\n\n
\nI seldom feel nervous.\n\n
\nI really enjoy talking to people.\n\n
\nI have an active fantasy life.\n\n
\nI'm suspicious when someone does something nice for me.\n\n
\nI have good judgment.\n\n
\nI often get disgusted with people I have to deal with.\n\n
\nI shy away from crowds of people.\n\n
\nMy body is bad and rotten inside\n\n
\nWatching ballet or modern dance bores me.\n\n
\nI would hate to be thought of as a hypocrite.\n\n
\nI never seem to be able to get organized.\n\n
\nI tend to blame myself when anything goes wrong.\n\n
\nOther people often look to me to make decisions.\n\n
\nWithout strong emotions, life would be uninteresting to me.\n\n
\nSome people think I'm selfish and egotistical.\n\n
\nWhen I make a commitment, I can always be counted on to follow through.\n\n
\nAt times I have been so ashamed I just wanted to hide.\n\n
\nMy work is likely to be slow but steady.\n\n
\nI got sick because of the bad weather we have been having\n\n
\nI prefer to spend my time in familiar surroundings.\n\n
\nI would rather cooperate with others than compete with them.\n\n
\nI'm not very ambitious.\n\n
\nIt doesn't bother me too much if I can't get what I want.\n\n
\nI often crave excitement.\n\n
\nI enjoy solving problems or puzzles.\n\n
\nI'm better than most people, and I know it.\n\n
\nI am a productive person who always gets the job done.\n\n
\nIt's often hard for me to make up my mind.\n\n
\nI'm not happy-go-lucky.\n\n
\nMy hands shake so much that people can easily notice\n\n
\nI believe that it's better to stick to your own principles than to be open-minded.\n\n
\nHuman need is more important than economics.\n\n
\nOccasionally I act first and think later.\n\n
\nI often feel tense and jittery.\n\n
\nI really like most people I meet.\n\n
\nIf I feel my mind starting to drift off into daydreams, I usually get busy and start concentrating on some work or activity instead.\n\n
\nMy first reaction is to trust people.\n\n
\nI often come into situations without being fully prepared.\n\n
\nI am not considered a touchy or temperamental person.\n\n
\nI'd rather vacation at a popular beach than an isolated cabin in the woods.\n\n
\nI still like to go out and meet people\n\n
\nCertain kinds of music have an endless fascination for me.\n\n
\nSometimes I trick people into doing what I want.\n\n
\nI'm picky about how jobs should be done.\n\n
\nI have a low opinion of myself.\n\n
\nI would rather go my own way than be a leader of others.\n\n
\nI seldom notice the moods or feelings that different environments produce.\n\n
\nMost people I know like me.\n\n
\nI follow my ethical principles strictly.\n\n
\nI seldom feel self-conscious when I'm around people.\n\n
\nI usually seem to be in a hurry.\n\n
\nI think I appear calm on the outside\n\n
\nI think it's interesting to learn and develop new hobbies.\n\n
\nI can be sarcastic and cutting when I need to be.\n\n
\nI have a clear set of goals and work toward them in an orderly fashion.\n\n
\nWhen I am having my favorite foods, I tend to eat too much.\n\n
\nI have sometimes done things just for "kicks" or "thrills."\n\n
\nI sometimes lose interest when people talk about very abstract, theoretical matters.\n\n
\nI'm not a show-off.\n\n
\nWhen a project gets too difficult, I'm inclined to start a new one.\n\n
\nI can handle myself pretty well in a crisis.\n\n
\nSometimes I bubble with happiness.\n\n
\nI wish I were a better person.\n\n
\nI think I am as good a person as anybody else\n\n
\nOur ideas of right and wrong may not be right for everyone in the world.\n\n
\nI believe all human beings are worthy of respect.\n\n
\nI think things through before coming to a decision.\n\n
\nI have fewer fears than most people.\n\n
\nI'm known as a warm and friendly person.\n\n
\nAs a child I rarely enjoyed games of make believe.\n\n
\nI think most of the people I deal with are honest and trustworthy.\n\n
\nI have many skills.\n\n
\nAt times I have felt bitter and resentful.\n\n
\nSocial gatherings are usually boring to me.\n\n
\nMy trouble is the result of some serious internal disease\n\n
\nI am intrigued by the patterns I find in art and nature.\n\n
\nBeing perfectly honest is a bad way to do business.\n\n
\nI'm not compulsive about cleaning.\n\n
\nSometimes things look pretty bleak and hopeless to me.\n\n
\nIn conversations, I tend to do most of the talking.\n\n
\nI find it easy to empathize - to feel myself what others are feeling.\n\n
\nI think of myself as a charitable person.\n\n
\nI try to do jobs carefully, so they won't have to be done again.\n\n
\nIf I have said or done the wrong thing to someone, I can hardly bear to face them again.\n\n
\nI act forcefully and energetically.\n\n
\nI have been thinking about trying to kill myself\n\n
\nI like the old-fashioned methods I'm used to.\n\n
\nIf I don't like people, I let them know it.\n\n
\nI strive for excellence in everything I do.\n\n
\nSometimes I do things on impulse that I later regret.\n\n
\nI like loud music.\n\n
\nI have a lot of intellectual curiosity.\n\n
\nI would rather praise others than be praised myself.\n\n
\nI waste a lot of time before settling down to work.\n\n
\nWhen everything seems to be going wrong, I can still make good decisions.\n\n
\nI am not a cheerful optimist.\n\n
\nI get hardly anything done lately\n\n
\nI believe letting students hear controversial speakers can only confuse and mislead them.\n\n
\nI have sympathy for others less fortunate than me.\n\n
\nI plan ahead carefully when I go on a trip.\n\n
\nFrightening thoughts sometimes come into my head.\n\n
\nI take a personal interest in the people I work with.\n\n
\nI don't like to waste my time daydreaming.\n\n
\nI have a good deal of faith in human nature.\n\n
\nI'm known for my common sense.\n\n
\nEven minor annoyances can be frustrating to me.\n\n
\nI really feel the need for other people if I am by myself for long.\n\n
\nThere is only misery in the future for me\n\n
\nI enjoy reading poetry that emphasizes feelings and images more than story lines.\n\n
\nI'm pretty slick when it comes to dealing with people.\n\n
\nI spend a lot of time looking for things I've misplaced.\n\n
\nI have sometimes experienced a deep sense of guilt or sinfulness.\n\n
\nSometimes I don't stand up for my rights like I should.\n\n
\nHow I feel about things is important to me.\n\n
\nI try to be courteous to everyone I meet.\n\n
\nI try to perform all the tasks assigned to me conscientiously.\n\n
\nI feel awkward around people.\n\n
\nI often feel as if I'm bursting with energy.\n\n
\nI worry a lot about my bodily symptoms\n\n
\nI follow the same route when I go someplace.\n\n
\nI sometimes get into arguments.\n\n
\nI'm something of a "workaholic."\n\n
\nI am always able to keep my feelings under control.\n\n
\nI like being part of the crowd at sporting events.\n\n
\nI have a wide range of intellectual interests.\n\n
\nI'm a superior person.\n\n
\nI have a lot of self-discipline.\n\n
\nI feel I am capable of coping with most of my problems.\n\n
\nI laugh easily.\n\n
\nI have to force myself to eat even a little\n\n
\nPeople should honor traditional values, not question them.\n\n
\nI would rather be known as "merciful" than as "just."\n\n
\nI think twice before I answer a question.\n\n
\nI have tried to answer all of these questions honestly and accurately.\n\n
\nHave you responded to all of the statements?\n\n
\nHave you entered your responses using the correct button?\n\n
\nI have my own plan for how to stay or become well.\n\n
\nI have goals in life that I want to reach.\n\n
\nI'm hopeful about my future.\n\n
\nCoping with my mental illness is no longer the main focus of my life.\n\n
\nI am exhausted much of the time\n\n
\nI have people in the community I can count on.\n\n
\nMy mental health providers encourage me to take the lead in setting my personal treatment and life goals.\n\n
\nDo you currently get support for your recovery from your spouse or significant other?\n\n
\nDo you currently get support for your recovery from other family members?\n\n
\nDo you currently get support for your recovery from friends?\n\n
\nWould you like a change in the kind or amount of support for your recovery that you are getting from your spouse or significant other? (If you do not have a spouse or significant other but want one, \nplease check "Yes, more support".)\n\n
\nWould you like a change in the kind or amount of support for your recovery that you are getting from other family members?\n\n
\nWould you like a change in the kind or amount of support for your recovery that you are getting from friends? (If you do not have as many friends as you would like but want one or more additional \nfriends, please check "Yes, more support".)\n\n
\nChoose the following sentence that best describes your current goal about your housing:\n\n
\nChoose the following sentence that best describes your current situation:\n\n
\nI can tell that I have lost a lot of weight\n\n
\nChoose the following sentence that best describes your current goal regarding employment:\n\n
\nChoose the following sentence that best describes your current situation:\n\n
\nChoose the following sentence that best describes your current interest in being involved in the community:\n\n
\nChoose the following sentence that best describes your current situation:\n\n
\nIs there any indication that the person engaged in self-directed violent behavior, either preparatory or potentially harmful?\n\n
\nIs there any indication that the person had self-directed violence related thoughts?\n\n
\nWere/Are the thoughts suicidal?\n\n
\nDid the behavior involve any injury?\n\n
\nWas the injury fatal?\n\n
\nWas the behavior preparatory only?\n\n
\nIn the past year, have you had 2 weeks or more\nduring which you felt sad, blue, or depressed;\nor when you lost all interest or pleasure in\nthings that you usually cared about or enjoyed?\n \n\n
\nWas the behavior interrupted by self or other(s)?\n\n
\nIs there evidence of Suicidal Intent?\n\n
\nAmbulation:\n\n
\nActivity and Evidence of Disease:\n\n
\nSelf Care:\n\n
\nIntake:\n\n
\nConscious Level:\n\n
\nRATE PSYCHOLOGICAL PAIN (hurt, anguish, or misery in your mind, not stress, not physical pain):\n\n
\nWhat I find most painful is:\n\n
\nRank of importance:\n\n
\nExtremity Movements\n \nLower (legs, knees, ankles, toes),\ne.g., lateral knee movement, foot tapping, heel dropping, foot squirming,\nInversion and eversion of foot.\n \n\n
\nI'm so weak.\n\n
\nHave you had 2 years or more in your life\nwhen you felt depressed or sad most days,\neven if you felt okay sometimes?\n \n\n
\nRATE STRESS (your general feeling of being pressured or overwhelmed):\n\n
\nWhat I find most stressful is:\n\n
\nRank of importance:\n\n
\nRATE AGITATION (emotional urgency; feeling that you need to take action; not irritation; not annoyance):\n\n
\nI most need to take action when:\n\n
\nRank of importance:\n\n
\nRATE HOPELESSNESS (your expectation that things will not get better no matter what you do):\n\n
\nI am most hopeless about:\n\n
\nRank of importance:\n\n
\nRATE SELF-HATE (your general feeling of disliking yourself; having no self-esteem; having no self-respect):\n\n
\nHave you felt depressed or sad much of the\ntime in the past year?\n \n\n
\nWhat I hate most about myself is:\n\n
\nRank of importance:\n\n
\nRATE OVERALL RISK OF SUICIDE:\n\n
\nHow much is being suicidal related to thoughts and feelings about yourself?\n\n
\nHow much is being suicidal related to thoughts and feelings about others?\n\n
\nAmbulation:\n\n
\nActivity and Evidence of Disease (Full Ambulation):\n\n
\nActivity and Evidence of Disease (Reduced Ambulation):\n\n
\nActivity and Evidence of Disease ( Mainly Sit/Lie Ambulation):\n\n
\nActivity and Evidence of Disease ( Mainly in Bed Ambulation):\n\n
\nHow much of the time during the PAST WEEK did you feel depressed?\n \n\n
\nSelf-Care (Full Ambulation):\n\n
\nSelf-Care (Reduced Ambulation):\n\n
\nPlease make a check mark in the appropriate box to indicate when you are filling out this form:\n\n
\nI tend to bounce back quickly after hard times.\n\n
\nIntake (Less than Full Ambulation):\n\n
\nI have a hard time making it through stressful events.\n\n
\nSelf Care (Mainly Sit/Lie Ambulation):\n\n
\nSelf-Care (Mainly in Bed Ambulation):\n\n
\nConscious Level (Mainly / Totally Bed Bound):\n\n
\nI like mechanics magazines.\n\n
\nDo you have or have you had\nAnemia?\n\n
\nI have a good appetite.\n\n
\nI think I would like the work of a librarian.\n\n
\nMy daily life is full of things that keep me interested.\n\n
\nAt times I have very much wanted to leave home.\n\n
\nI find it hard to keep my mind on a task or job.\n\n
\nMy mother is a good woman, or (if your mother is dead) my mother was a good woman.\n\n
\nWhen I have a problem it helps to talk it over with someone.\n\n
\nI often feel guilty because I pretend to feel more sorry about something than I really do.\n\n
\nIt takes a lot of argument to convince most people of the truth.\n\n
\nI love to go to dances.\n\n
\nArthritis or any kind of rheumatism?\n\n
\nI often feel I can read other people's minds.\n\n
\nI sometimes keep on at a thing until others lose their patience with me.\n\n
\nEvil spirits possess me at times.\n\n
\nThere seems to be a lump in my throat much of the time.\n\n
\nAt times I feel like swearing.\n\n
\nI am a very sociable person.\n\n
\nI feel weak all over much of the time.\n\n
\nThe members of my family and my close relatives get along quite well.\n\n
\nI feel uneasy indoors.\n\n
\nSometimes when I was young I stole things.\n\n
\nAsthma?\n\n
\nI wish I could be as happy as others seem to be.\n\n
\nAt times I feel like smashing things.\n\n
\nI am easily downed in an argument.\n\n
\nI am about as able to work as I ever was.\n\n
\nWhen people do me a wrong, I feel I should pay them back if I can, just for the principle of the thing.\n\n
\nI have often lost out on things because I couldn't make up my mind soon enough.\n\n
\nMy hands and feet are usually warm enough.\n\n
\nI am apt to take disappointments so keenly that I can't put them out of my mind.\n\n
\nMost of the time I feel blue.\n\n
\nI cannot understand what I read as well as I used to.\n\n
\nBronchitis?\n\n
\nI have had very peculiar and strange experiences.\n\n
\nI have a cough most of the time.\n\n
\nGhosts or spirits can influence people for good or bad.\n\n
\nI frequently have to fight against showing that I am bashful.\n\n
\nI think a great many people exaggerate their misfortunes in order to gain the sympathy and help of others.\n\n
\nMy feelings are not easily hurt.\n\n
\nI have never been in trouble because of my sex behavior.\n\n
\nI have often had to take orders from someone who did not know as much as I did.\n\n
\nMost anytime I would rather sit and daydream than do anything else.\n\n
\nSometimes I enjoy hurting persons I love.\n\n
\nCancer?\n\n
\nI would like to be a soldier.\n\n
\nI am troubled by attacks of nausea and vomiting.\n\n
\nI find it hard to make talk when I meet new people.\n\n
\nI do not always tell the truth.\n\n
\nWhen I am with people, I am bothered by hearing very strange things.\n\n
\nI like to go to parties and other affairs where there is lots of loud fun.\n\n
\nI am certainly lacking in self-confidence.\n\n
\nI have enjoyed using marijuana.\n\n
\nI would like to be a singer.\n\n
\nI have been afraid of things or people that I knew could not hurt me.\n\n
\nCataracts?\n\n
\nI am very seldom troubled by constipation.\n\n
\nAt times I am all full of energy.\n\n
\nLightning is one of my fears.\n\n
\nI think most people would lie to get ahead.\n\n
\nI get anxious and upset when I have to make a short trip away from home.\n\n
\nI enjoy social gatherings just to be with people.\n\n
\nSome of my family have habits that bother and annoy me very much.\n\n
\nMy memory seems to be all right.\n\n
\nI frequently find it necessary to stand up for what I think is right.\n\n
\nI have never done anything dangerous for the thrill of it.\n\n
\nDiabetes?\n\n
\nI do many things which I regret afterwards (I regret things more than others seem to).\n\n
\nI have often felt that strangers were looking at me critically.\n\n
\nI am an important person.\n\n
\nI am almost never bothered by pains over my heart or in my chest.\n\n
\nIn school I was sometimes sent to the principal for bad behavior.\n\n
\nI dislike having people around me.\n\n
\nI usually have to stop and think before I act even in small matters.\n\n
\nMy hands have not become clumsy or awkward.\n\n
\nI do not read every editorial in the newspaper every day.\n\n
\nI believe I am being plotted against.\n\n
\nMy life's not going the way I want it to.\n\n
\nGall bladder trouble?\n\n
\nAt times my thoughts have raced ahead faster than I could speak them.\n\n
\nI believe I am no more nervous than most others.\n\n
\nMuch of the time I feel as if I have done something wrong or evil.\n\n
\nI think I would like the kind of work a forest ranger does.\n\n
\nI am bothered by an upset stomach several times a week.\n\n
\nI am so touchy on some subjects that I can't talk about them.\n\n
\nMy hearing is apparently as good as that of most people.\n\n
\nI have nightmares every few nights.\n\n
\nI have very few quarrels with members of my family.\n\n
\nAt times I have fits of laughing and crying that I cannot control.\n\n
\nHeart disease?\n\n
\nI do not have a great fear of snakes.\n\n
\nI usually feel that life is worthwhile.\n\n
\nAt times I feel like picking a fist fight with someone.\n\n
\nI have never seen a vision.\n\n
\nI can express my true feelings only when I drink.\n\n
\nMost people are honest chiefly because they are afraid of being caught.\n\n
\nI hardly ever feel pain in the back of my neck.\n\n
\nI certainly feel useless at times.\n\n
\nI am afraid of finding myself in a closet or small closed place.\n\n
\nI am easily embarrassed.\n\n
\nHigh blood pressure?\n\n
\nI believe I am being followed.\n\n
\nI have recently considered killing myself.\n\n
\nI do not mind meeting strangers.\n\n
\nOnce in a while I put off until tomorrow what I ought to do today.\n\n
\nMy parents often objected to the kind of people I went around with.\n\n
\nI like to know some important people because it makes me feel important.\n\n
\nI love my father, or (if your father is dead) I loved my father.\n\n
\nMost people will use somewhat unfair means to gain profit or an advantage rather than to lose it.\n\n
\nI like poetry.\n\n
\nMuch of the time my head seems to hurt all over.\n\n
\nKidney trouble?\n\n
\nI seem to be about as capable and smart as most others around me.\n\n
\nOnce in a while I feel hate toward members of my family whom I usually love.\n\n
\nI strongly defend my own opinions as a rule.\n\n
\nI am happy most of the time.\n\n
\nI have had periods in which I carried on activities without knowing later what I had been doing.\n\n
\nI like to talk about sex.\n\n
\nI have several times given up doing a thing because I thought too little of my ability.\n\n
\nI enjoy the excitement of a crowd.\n\n
\nI feel that I have often been punished without cause.\n\n
\nI think I would like the work of a building contractor.\n\n
\nLung disease?\n\n
\nI am apt to pass up something I want to do because others feel that I am not going about it in the right way.\n\n
\nI have little or no trouble with my muscles twitching or jumping.\n\n
\nI wish I were not so shy.\n\n
\nI am not afraid of fire.\n\n
\nI am inclined to take things hard.\n\n
\nThere is something wrong with my mind.\n\n
\nI like to flirt.\n\n
\nI easily become impatient with people.\n\n
\nMost of the time I wish I were dead.\n\n
\nIt is safer to trust nobody.\n\n
\nMigraine headaches?\n\n
\nI have had attacks in which I could not control my movements or speech but in which I knew what was going on around me.\n\n
\nI worry quite a bit over possible misfortunes.\n\n
\nI have never been in love with anyone.\n\n
\nMy speech is the same as always (not faster or slower, no slurring or hoarseness).\n\n
\nI liked school.\n\n
\nI get angry sometimes.\n\n
\nI am not afraid to handle money.\n\n
\nSomeone has been trying to poison me.\n\n
\nI brood a great deal.\n\n
\nWhen I get bored I like to stir up some excitement.\n\n
\nRepeated bladder disorders?\n\n
\nOften I cross the street in order not to meet someone I see.\n\n
\nEverything tastes the same.\n\n
\nI am not easily angered.\n\n
\nIt bothers me greatly to think of making changes in my life.\n\n
\nI cannot keep my mind on one thing.\n\n
\nThere seems to be a fullness in my head or nose most of the time.\n\n
\nMy parents and family find more fault with me than they should.\n\n
\nI often hear voices without knowing where they come from.\n\n
\nI enjoy many different kinds of play and recreation.\n\n
\nI have used alcohol excessively.\n\n
\nRepeated seizures?\n\n
\nMost people make friends because friends are likely to be useful to them.\n\n
\nI have at times stood in the way of people who were trying to do something, not because it amounted to much but because of the principle of the thing.\n\n
\nI have difficulty in starting to do things.\n\n
\nI would like to be a florist.\n\n
\nAlmost every day something happens to frighten me.\n\n
\nI like to let people know where I stand on things.\n\n
\nI very much like hunting.\n\n
\nSometimes some unimportant thought will run through my mind and bother me for days.\n\n
\nSomeone has been trying to rob me.\n\n
\nA windstorm terrifies me.\n\n
\nRepeated stomach problems?\n\n
\nI feel like giving up quickly when things go wrong.\n\n
\nMy worries seem to disappear when I get into a crowd of lively friends.\n\n
\nMy table manners are not quite as good at home as when I am out in company.\n\n
\nI get mad easily and then get over it soon.\n\n
\nI can remember "playing sick" to get out of something.\n\n
\nAnyone who is able and willing to work hard has a good chance of succeeding.\n\n
\nLife is a strain for me much of the time.\n\n
\nI have had blank spells in which my activities were interrupted and I did not know what was going on around me.\n\n
\nAt times I feel that I can make up my mind with unusually great ease.\n\n
\nBad words, often terrible words, come into my mind and I cannot get rid of them.\n\n
\nRepeated trouble with neck, back, or spine?\n\n
\nI seldom or never have dizzy spells.\n\n
\nI wake up fresh and rested most mornings.\n\n
\nLately I have thought a lot about killing myself.\n\n
\nI am often afraid of the dark.\n\n
\nSometimes without any reason or even when things are going wrong I feel excitedly happy, "on top of the world."\n\n
\nIt makes me nervous to have to wait.\n\n
\nThere are persons who are trying to steal my thoughts and ideas.\n\n
\nThe future seems hopeless to me.\n\n
\nI can sleep during the day but not at night.\n\n
\nI think nearly anyone would tell a lie to keep out of trouble.\n\n
\nI'm so disappointed in myself.\n\n
\nStroke?\n\n
\nOften, even though everything is going fine for me, I feel that I don't care about anything.\n\n
\nI got many beatings when I was a child.\n\n
\nDuring the past few years I have been well most of the time.\n\n
\nI am never happier than when alone.\n\n
\nOften I feel as if there is a tight band around my head.\n\n
\nI am likely not to speak to people until they speak to me.\n\n
\nIt would be better if almost all laws were thrown away.\n\n
\nSometimes my voice leaves me or changes even though I have no cold.\n\n
\nThe things that some of my family have done have frightened me.\n\n
\nOnce a week or oftener I become very excited.\n\n
\nTuberculosis?\n\n
\nI am entirely self-confident.\n\n
\nI would rather win than lose in a game.\n\n
\nI have no fear of water.\n\n
\nMost people inwardly dislike putting themselves out to help other people.\n\n
\nI have never had a fit or convulsion.\n\n
\nI have sometimes felt that difficulties were piling up so high that I could not overcome them.\n\n
\nIf I were a reporter I would very much like to report sporting news.\n\n
\nI have very few headaches.\n\n
\nI have never been in trouble with the law.\n\n
\nIn walking I am very careful to step over sidewalk cracks.\n\n
\nUlcer?\n\n
\nAfter a bad day, I usually need a few drinks to relax.\n\n
\nAt times I have been so entertained by the cleverness of some criminals that I have hoped they would get away with it.\n\n
\nI am sure I am being talked about.\n\n
\nSomething exciting will almost always pull me out of it when I am feeling low.\n\n
\nI like dramatics.\n\n
\nI am usually very direct with people I am trying to correct or improve.\n\n
\nI shrink from facing a crisis or difficulty.\n\n
\nPeculiar odors come to me at times.\n\n
\nI have more trouble concentrating than others seem to have.\n\n
\nI like parties and socials.\n\n
\nHave you ever spent any time as a patient in a hospital\nfor mental or emotional problems?\n\n
\nI have never felt better in my life than I do now.\n\n
\nMy soul sometimes leaves my body.\n\n
\nEven when I am with people I feel lonely much of the time.\n\n
\nWhen I was young I often did not go to school even when I should have gone.\n\n
\nI wish I could get over worrying about things I have said that may have injured other people's feelings.\n\n
\nI have periods in which I feel unusually cheerful without any special reason.\n\n
\nI am afraid of using a knife or anything very sharp or pointed.\n\n
\nI have certainly had more than my share of things to worry about.\n\n
\nI am troubled by discomfort in the pit of my stomach every few days or oftener.\n\n
\nI do not like everyone I know.\n\n
\nDo any blood relatives (mother, father, sisters, or brothers)\nhave a history of problems with depression or alcoholism?\n\n
\nI have no enemies who really wish to harm me.\n\n
\nPeople generally demand more respect for their own rights than they are willing to allow for others.\n\n
\nAlthough I am not happy with my life, there is nothing I can do about it now.\n\n
\nI often have serious disagreements with people who are close to me.\n\n
\nAt times I hear so well it bothers me.\n\n
\nI very seldom have spells of the blues.\n\n
\nAt times it has been impossible for me to keep from stealing or shoplifting something.\n\n
\nSometimes I become so excited that I find it hard to get to sleep.\n\n
\nI have no fear of spiders.\n\n
\nI believe in law enforcement.\n\n
\nHow old were you the first time you had a period when\nyou felt sad, blue, or depressed for 2 weeks or more?\n \n\n
\nI seem to make friends about as quickly as others do.\n\n
\nI was suspended from school one or more times for bad behavior.\n\n
\nI always have too little time to get things done.\n\n
\nI have been told that I walk during sleep.\n\n
\nI would like to be an auto racer.\n\n
\nI have had no difficulty in keeping my balance in walking.\n\n
\nI feel anxiety about something or someone almost all the time.\n\n
\nI am apt to pass up something I want to do when others feel that it isn't worth doing.\n\n
\nI have a great deal of stomach trouble.\n\n
\nI can easily make other people afraid of me, and sometimes do for the fun of it.\n\n
\nBefore the current episode, how many different times in your life\nhave you had a period when you felt sad, blue, or depressed\nfor at least 2 weeks?\n \n\n
\nAt times I think I am no good at all.\n\n
\nPeople say insulting and vulgar things about me.\n\n
\nI am not feeling much pressure or stress these days.\n\n
\nI am bothered by people outside, on the streets, in stores, etc., watching me.\n\n
\nI don't like hearing other people give their opinions about life.\n\n
\nExcept by doctor's orders I never take drugs or sleeping pills.\n\n
\nWhen a man is with a woman he is usually thinking about things related to her sex.\n\n
\nIf given the chance I would make a good leader of people.\n\n
\nI often feel as if things are not real.\n\n
\nI gossip a little at times.\n\n
\nDid this current period of feeling sad occur just after\nsomeone close to you died?\n\n
\nThe top of my head sometimes feels tender.\n\n
\nDirt frightens or disgusts me.\n\n
\nIf given the chance I could do some things that would be of great benefit to the world.\n\n
\nIf I were a reporter I would very much like to report news of the theater.\n\n
\nI usually expect to succeed in things I do.\n\n
\nI feel tired a good deal of the time.\n\n
\nI am often said to be hotheaded.\n\n
\nIn school I found it very hard to talk in front of the class.\n\n
\nI am often sorry because I am so irritable and grouchy.\n\n
\nNo one knows it but I have tried to kill myself.\n\n
\nHow many people do you feel you can tell just about\nanything to, people you can count on for understanding\nor support?\n \n\n
\nSomeone has control over my mind.\n\n
\nIn school my marks in classroom behavior were quite regularly bad.\n\n
\nI hardly ever notice my heart pounding and I am seldom short of breath.\n\n
\nIt does not bother me particularly to see animals suffer.\n\n
\nI have often met people who were supposed to be experts who were no better than I.\n\n
\nI have strange and peculiar thoughts.\n\n
\nI dread the thought of an earthquake.\n\n
\nI like repairing a door latch.\n\n
\nI have frequently worked under people who seem to have things arranged so that they get credit for good work but are able to pass off mistakes onto those under them.\n\n
\nI sometimes feel that I am about to go to pieces.\n\n
\nDuring the past 2 years, have you felt depressed or sad\nmost days?\n\n
\nI am in just as good physical health as most of my friends.\n\n
\nI must admit that I have at times been worried beyond reason over something that really did not matter.\n\n
\nSomeone has it in for me.\n\n
\nI have few or no pains.\n\n
\nI have a drug or alcohol problem.\n\n
\nI have had periods when I felt so full of pep that sleep did not seem necessary for days at a time.\n\n
\nI never worry about my looks.\n\n
\nWhen things get really bad, I know I can count on my family for help.\n\n
\nAt one or more times in my life I felt that someone was making me do things by hypnotizing me.\n\n
\nIt makes me angry to have people hurry me.\n\n
\nNothing feels good anymore.\n\n
\nDuring the past 2 years, was there a period of 2 months or\nmore when you did not feel depressed or sad most days?\n\n
\nI have no trouble swallowing.\n\n
\nI hear strange things when I am alone.\n\n
\nI usually have a hard time deciding what to do.\n\n
\nSeveral times a week I feel as if something dreadful is about to happen.\n\n
\nWhen people do something that makes me angry, I let them know how I feel about it.\n\n
\nI frequently notice my hand shakes when I try to do something.\n\n
\nWhenever possible I avoid being in a crowd.\n\n
\nMost men are unfaithful to their wives now and then.\n\n
\nOften I get confused and forget what I want to say.\n\n
\nMy people treat me more like a child than a grown-up.\n\n
\nDuring the past 4 weeks, how many days did your physical\nhealth or emotional problems keep you in bed all or most of\nthe day?\n \n\n
\nMy main goals in life are within my reach.\n\n
\nTalking over problems and worries with someone is often more helpful than taking drugs or medicine.\n\n
\nI am afraid of being alone in a wide-open place.\n\n
\nAt times I can't seem to stop talking.\n\n
\nI am not afraid of mice.\n\n
\nSomeone has been trying to influence my mind.\n\n
\nI often feel that I'm not as good as other people.\n\n
\nI have often been frightened in the middle of the night.\n\n
\nI do not often notice my ears ringing or buzzing.\n\n
\nI am never happier than when I am by myself.\n\n
\nDuring the past 4 weeks, how many days did you cut down\non the things you usually do for one-half day or more\nbecause of your physical health or emotional problems?\n(Do not include days already counted in Question 29.)\n \n\n
\nI like to keep people guessing what I'm going to do next.\n\n
\nI am usually calm and not easily upset.\n\n
\nI see things or animals or people around me that others do not see.\n\n
\nI have no dread of going into a room by myself where other people have already gathered and are talking.\n\n
\nI would like to be a journalist.\n\n
\nOnce a week or more I get high or drunk.\n\n
\nSometimes in elections I vote for people about whom I know very little.\n\n
\nI feel helpless when I have to make some important decisions.\n\n
\nI really like playing rough sports (such as football or soccer).\n\n
\nI have numbness in one or more places on my skin.\n\n
\nDuring the past 4 weeks, did you work at any time at a\njob or business not counting work around the house?\n\n
\nI like making decisions and assigning jobs to others.\n\n
\nI often become very irritable when people interrupt my work.\n\n
\nIn most marriages one or both partners are unhappy.\n\n
\nI would certainly enjoy beating criminals at their own game.\n\n
\nI forget where I leave things.\n\n
\nTerrible thoughts about my family come to me at times.\n\n
\nMy neck spots with red often.\n\n
\nI worry a great deal over money.\n\n
\nPeople are not very kind to me.\n\n
\nSometimes I am sure that other people can tell what I am thinking.\n\n
\nDuring the past 4 weeks, how many days did you miss\nmore than half of the day from your job or business\nbecause of illness or injury?\n \n\n
\nI have gotten angry and broken furniture or dishes when I was drinking.\n\n
\nI have never been paralyzed or had any unusual weakness of any of my muscles.\n\n
\nI hate my whole family.\n\n
\nI am so sick of what I have to do every day that I just want to get out of it all.\n\n
\nI have at times had to be rough with people who were rude or annoying.\n\n
\nI can't go into a dark room alone even in my own home.\n\n
\nSometimes I get so angry and upset I don't know what comes over me.\n\n
\nI sometimes find it hard to stick up for my rights because I am so reserved.\n\n
\nI am made nervous by certain animals.\n\n
\nI like to drive a hard bargain.\n\n
\nDuring the past 4 weeks, to what extent did emotional\nproblems interfere with your social activities?\n \n\n
\nCriticism or scolding hurts me terribly.\n\n
\nWhen I am sad, visiting with friends can always pull me out of it.\n\n
\nHaving to make important decisions makes me nervous.\n\n
\nOnce in a while I laugh at a dirty joke.\n\n
\nMost married couples don't show much affection for each other.\n\n
\nI am often inclined to go out of my way to win a point with someone who has opposed me.\n\n
\nIf I get upset I'm sure to get a headache.\n\n
\nI've been so angry at times that I've hurt someone in a physical fight.\n\n
\nI sometimes seem to hear my thoughts being spoken out loud.\n\n
\nWhen my life gets difficult, it makes me want to just give up.\n\n
\nDid you ever think that you were an excessive drinker?\n\n
\nIf people had not had it in for me, I would have been much more successful.\n\n
\nI do not tire quickly.\n\n
\nMy thoughts these days turn more and more to death and the life hereafter.\n\n
\nI get angry with myself for giving in to other people so much.\n\n
\nI recognize several faults in myself that I will not be able to change.\n\n
\nI have become so angry with someone that I have felt as if I would explode.\n\n
\nI frequently find myself worrying about something.\n\n
\nHow important is HEALTH to your happiness?\n\n
\nHow satisfied are you with your HEALTH?\n\n
\nHow important is SELF-ESTEEM to your happiness?\n\n
\nHave you ever drunk as much as a fifth of liquor in one day?\nThat would be about 20 drinks, or 3 bottles of wine,\nor as much as 3 six-packs of beer in one day.\n \n\n
\nHow satisfied are you with your SELF-ESTEEM?\n\n
\nHow important are GOALS-AND-VALUES to your happiness?\n\n
\nHow satisfied are you with your GOALS-AND-VALUES?\n\n
\nHow important is MONEY to your happiness?\n\n
\nHow satisfied are you with the MONEY you have?\n\n
\nHow important is WORK to your happiness?\n\n
\nHow satisfied are you with your WORK? (If you are not working, say how satisfied you are about not working.)\n\n
\nHow important is PLAY to your happiness?\n\n
\nHow satisfied are you with the PLAY in your life?\n\n
\nHow important is LEARNING to your happiness?\n\n
\nHas there ever been a period of 2 weeks when\nevery day you were drinking 7 or more beers,\n\n
\nHow satisfied are you with your LEARNING?\n\n
\nHow important is CREATIVITY to your happiness?\n\n
\nHow satisfied are you with your CREATIVITY?\n\n
\nHow important is HELPING to your happiness?\n\n
\nHow satisfied are you with the HELPING you do?\n\n
\nHow important is LOVE to your happiness?\n\n
\nHow satisfied are you with the LOVE in your life? (If you are not in a LOVE relationship, say how satisfied you feel about not having a LOVE relationship.)\n\n
\nHow important are FRIENDS to your happiness?\n\n
\nHow satisfied are you with your FRIENDS? (If you have no FRIENDS, say how satisfied you are about having no FRIENDS.)\n\n
\nHow important are CHILDREN to your happiness? (If you have no CHILDREN, say how important having a child is to your happiness.)\n\n
\nHave you ever used one of the following substances\non your own more than 5 times in your life?\n"On your own," means to get high or without a prescription,\nor more than was prescribed.\n \nMarijuana (hashish, pot, grass)\n\n
\nHow satisfied are you with your relationships with your CHILDREN? (If you have no CHILDREN, say how satisfied you feel about not having children.)\n\n
\nHow important are RELATIVES to your happiness?\n\n
\nHow satisfied are you with your relationships with RELATIVES?\n\n
\nHow important is your HOME to your happiness?\n\n
\nHow satisfied are you with your HOME?\n\n
\nHow important is your NEIGHBORHOOD to your happiness?\n\n
\nHow satisfied are you with your NEIGHBORHOOD?\n\n
\nHow important is your COMMUNITY to your happiness?\n\n
\nHow satisfied are you with your COMMUNITY?\n\n
\nDate of administration:\n\n
\nI can't stand this anymore.\n\n
\nStimulants (speed, amphetamines, crystal, methamphetamines)\n\n
\nMethod of administration:\n\n
\nIt does not take me long to recover from a stressful event.\n\n
\nIt is hard for me to snap back when something bad happens.\n\n
\nI usually come through difficult times with little trouble.\n\n
\nI tend to take a long time to get over setbacks in my life.\n\n
\nFocus on your weakness.\n\n
\nHelp you to talk about changing your behavior.\n\n
\nAct as a partner in your behavior change.\n\n
\nHelp you to discuss your need to change your behavior.\n\n
\nMake you feel distrustful of him/her.\n\n
\nSedatives (barbiturates, sleeping pills, Quaaludes,\nXanax, tranquilizers, Valium, Librium, red devils)\n\n
\nHelp you examine the pros and cons of changing your behavior.\n\n
\nHelp you to feel hopeful about changing your behavior.\n\n
\nArgue with you to change your behavior.\n\n
\nChange the topic when you became upset about changing your behavior.\n\n
\nDate of administration:\n\n
\nMethod of administration:\n\n
\nIn the past 7 days, how would you say your physical health has been?\n\n
\nIn the past 7 days, how many nights did you have trouble falling asleep or staying asleep?\n\n
\nIn the past 7 days, how many days have you felt depressed, anxious, angry or very upset throughout most of the day?\n\n
\nIn the past 7 days, how many days did you drink ANY alcohol?\n\n
\nCocaine (coke, crack)\n\n
\nIn the past 7 days, how many days did you have at least 5 drinks (if you are a man) or at least 4 drinks (if you are a woman)? [One drink is considered one shot of hard liquor (1.5 oz.) or 12-ounce \ncan/bottle of beer or 5 ounce glass of wine.]\n\n
\nIn the past 7 days, how many days did you use any illegal or street drugs or abuse any prescription medications?\n\n
\nMarijuana (cannabis, pot, weed)?\n\n
\nSedatives and/or Tranquilizers (benzos, Valium, Xanax, Ativan, Ambien, barbs, Phenobarbital, downers, etc.)?\n\n
\nCocaine and/or Crack?\n\n
\nOther Stimulants (amphetamine, methamphetamine, Dexedrine, Ritalin, Adderall, speed, crystal meth, ice, etc.)?\n\n
\nOpiates (Heroin, Morphine, Dilaudid, Demerol, Oxycontin, oxy, codeine (Tylenol 2,3,4), Percocet, Vicodin, Fentanyl, etc.)?\n\n
\nInhalants (glues, adhesives, nail polish remover, paint thinner, etc.)?\n\n
\nOther drugs (steroids, non-prescription sleep and diet pills, Benadryl, Ephedra, other over-the-counter or unknown medications)?\n\n
\nIn the past 7 days, how much were you bothered by cravings or urges to drink alcohol or use drugs?\n\n
\nHeroin\n\n
\nHow confident are you that you will NOT use alcohol and drugs in the next 7 days?\n\n
\nIn the past 7 days, how many days did you attend self-help meetings like AA or NA to support your recovery?\n\n
\nIn the past 7 days, how many days were you in any situations or with any people that might put you at an increased risk for using alcohol or drugs (i.e., around risky "people, places or things")?\n\n
\nDoes your religion or spirituality help support your recovery?\n\n
\nIn the past 7 days, how many days did you spend much of the time at work, school, or doing volunteer work?\n\n
\nDo you have enough income (from legal sources) to pay for necessities such as housing, transportation, food and clothing for yourself and your dependents?\n\n
\nIn the past 7 days, how much have you been bothered by arguments or problems getting along with any family members or friends?\n\n
\nIn the past 7 days, how many days did you contact or spend time with any family members or friends who are supportive of your recovery?\n\n
\nHow satisfied are you with your progress toward achieving your recovery goals?\n\n
\nDate of administration:\n\n
\nOpiates (Other than heroin: codeine,\ndemerol, morphine, Methadone, Darvon, opium)\n\n
\nMethod of administration:\n\n
\nIn the past 7 days, how would you say your physical health has been?\n\n
\nIn the past 7 days, how many nights did you have trouble falling asleep or staying asleep?\n\n
\nIn the past 7 days, how many days have you felt depressed, anxious, angry or very upset throughout most of the day?\n\n
\nIn the past 7 days, how many days did you drink ANY alcohol?\n\n
\nIn the past 7 days, how many days did you have at least 5 drinks (if you are a man) or at least 4 drinks (if you are a woman)? [One drink is considered one shot of hard liquor (1.5 oz.) or 12-ounce \ncan/bottle of beer or 5-ounce glass of wine.]\n\n
\nIn the past 7 days, how many days did you use any illegal or street drugs or abuse any prescription medications?\n\n
\nMarijuana (cannabis, pot, weed)?\n\n
\nSedatives and/or Tranquilizers (benzos, Valium, Xanax, Ativan, Ambien, barbs, Phenobarbital, downers, etc.)?\n\n
\nCocaine and/or Crack?\n\n
\nPsychedelics (LSD, mescaline, peyote, psilocybin, mushrooms, DMT)\n\n
\nOther Stimulants (amphetamine, methamphetamine, Dexedrine, Ritalin, Adderall, speed, crystal meth, ice, etc.)?\n\n
\nOpiates (Heroin, Morphine, Dilaudid, Demerol, Oxycontin, oxy, codeine (Tylenol 2,3,4), Percocet, Vicodin, Fentanyl, etc.)?\n\n
\nInhalants (glues, adhesives, nail polish remover, paint thinner, etc.)?\n\n
\nOther drugs (steroids, non-prescription sleep and diet pills, Benadryl, Ephedra, other over-the-counter or unknown medications)?\n\n
\nIn the past 7 days, how much were you bothered by cravings or urges to drink alcohol or use drugs?\n\n
\nHow confident are you in your ability to be completely abstinent (clean) from alcohol and drugs in the next 7 days?\n\n
\nIn the past 7 days, how many days did you attend self-help meetings like AA or NA to support your recovery?\n\n
\nIn the past 7 days, how many days were you in any situations or with any people that might put you at an increased risk for using alcohol or drugs (i.e., around risky "people, places or things")?\n\n
\nDoes your religion or spirituality help support your recovery?\n\n
\nIn the past 7 days, how many days did you spend much of the time at work, school, or doing volunteer work?\n\n
\nPCP\n\n
\nDo you have enough income (from legal sources) to pay for necessities such as housing, transportation, food and clothing for yourself and your dependents?\n\n
\nIn the past 7 days, how much have you been bothered by arguments or problems getting along with any family members or friends?\n\n
\nIn the past 7 days, how many days were you in contact or spent time with any family members or friends who are supportive of your recovery?\n\n
\nHow satisfied are you with your progress toward achieving your recovery goals?\n\n
\nIn the past 30 days, how many days did you drink ANY alcohol?\n\n
\nIn the past 30 days, how many days did you have at least 5 drinks (if you are a man) or at least 4 drinks (if you are a woman)? [One drink is considered one shot of hard liquor (1.5 oz.) or 12-ounce \ncan/bottle of beer or 5-ounce glass of wine.]\n\n
\nIn the past 30 days, how many days did you use any illegal or street drugs or abuse any prescription medications?\n\n
\nMarijuana (cannabis, pot, weed)?\n\n
\nSedatives and/or Tranquilizers (benzos, Valium, Xanax, Ativan, Ambien, barbs, Phenobarbital, downers, etc.)?\n\n
\nCocaine and/or Crack?\n\n
\nInhalants (glue, toluene, gasoline, paint)\n\n
\nOther Stimulants (amphetamine, methamphetamine, Dexedrine, Ritalin, Adderall, speed, crystal meth, ice, etc.)?\n\n
\nOpiates (Heroin, Morphine, Dilaudid, Demerol, Oxycontin, oxy, codeine (Tylenol 2,3,4), Percocet, Vicodin, Fentanyl, etc.)?\n\n
\nInhalants (glues, adhesives, nail polish remover, paint thinner, etc.)?\n\n
\nOther drugs (steroids, non-prescription sleep and diet pills, Benadryl, Ephedra, other over-the-counter or unknown medications)?\n\n
\nDate of administration:\n\n
\nMethod of administration:\n\n
\nIn the past 30 days, how would you say your physical health has been?\n\n
\n Push you forward when you became unwilling to talk about an issue further.\n\n
\nAct as an authority on your life.\n\n
\nTell you what to do.\n\n
\nAny other substances (nitrous oxide, amyl nitrite)\n\n
\nDid you feel tired or fatigued during the day or evening?\n\n
\nWere you sleepy or drowsy during the day or evening?\n\n
\nDid you take any naps or fall asleep briefly during the day or evening?\n\n
\nDid you feel you had been getting an adequate amount of sleep?\n\n
\nPlease indicate the degree of happiness, all things considered, of your relationship.\n\n
\nIn general, how often do you think that things between you and your partner are going well?\n\n
\nOur relationship is strong.\n\n
\nMy relationship with my partner makes me happy.\n\n
\nI have a warm and comfortable relationship with my partner.\n\n
\nIn the past 30 days, how much were you bothered by cravings or urges to drink alcohol or use drugs?\n\n
\nDid you ever find you needed larger amounts of these\ndrugs to get an effect, or that you could no longer\nget high on the amount you used to use?\n\n
\nHow confident are you that you will NOT use alcohol and drugs in the next 30 days?\n\n
\nI really feel like part of a team with my partner.\n\n
\nHow rewarding is your relationship with your partner?\n\n
\nDoes your religion or spirituality help support your recovery?\n\n
\nHow well does your partner meet your needs?\n\n
\nDo you have enough income (from legal sources) to pay for necessities such as housing, transportation, food and clothing for yourself and your dependents?\n\n
\nIn the past 30 days, how much have you been bothered by arguments or problems getting along with any family members or friends?\n\n
\nTo what extent has your relationship met your original expectations?\n\n
\nHow satisfied are you with your progress toward achieving your recovery goals?\n\n
\nIn the past 30 days, how many nights did you have trouble falling asleep or staying asleep?\n\n
\nI can't get started.\n\n
\nDid you ever have any emotional or psychological\nproblems from using drugs--like feeling crazy or\nparanoid or depressed, or uninterested in things?\n\n
\nIn the past 30 days, how many days have you felt depressed, anxious, angry or very upset throughout most of the day?\n\n
\nIn the past 30 days, how many days did you drink ANY alcohol?\n\n
\nIn the past 30 days, how many days did you have at least 5 drinks (if you are a man) or at least 4 drinks (if you are a woman)? [One drink is considered one shot of hard liquor (1.5 oz.) or 12-ounce \ncan/bottle of beer or 5-ounce glass of wine.]\n\n
\nIn the past 30 days, how many days did you use any illegal or street drugs or abuse any prescription medications?\n\n
\nMarijuana (cannabis, pot, weed)?\n\n
\nSedatives and/or Tranquilizers (benzos, Valium, Xanax, Ativan, Ambien, barbs, Phenobarbital, downers, etc.)?\n\n
\nCocaine and/or Crack?\n\n
\nOther Stimulants (amphetamine, methamphetamine, Dexedrine, Ritalin, Adderall, speed, crystal meth, ice, etc.)?\n\n
\nOpiates (Heroin, Morphine, Dilaudid, Demerol, Oxycontin, oxy, codeine (Tylenol 2,3,4), Percocet, Vicodin, Fentanyl, etc.)?\n\n
\nInhalants (glues, adhesives, nail polish remover, paint thinner, etc.)?\n\n
\nHow often in the past 4 weeks have you felt depressed, blue,\nor in low spirits for most of the day?\n \n\n
\nOther drugs (steroids, non-prescription sleep and diet pills, Benadryl, Ephedra, other over-the-counter or unknown medications)?\n\n
\nIn the past 30 days, how many days did you attend self-help meetings like AA or NA to support your recovery?\n\n
\nIn the past 30 days, how many days were you in any situations or with any people that might put you at an increased risk for using alcohol or drugs (i.e., around risky "people, places or things")?\n\n
\nIn the past 30 days, how many days did you spend much of the time at work, school, or doing volunteer work?\n\n
\nIn the past 30 days, how many days did you contact or spend time with any family members or friends who are supportive of your recovery?\n\n
\nNumber:\n\n
\nDo you often feel tired, fatigued or sleepy during daytime?\n\n
\nDo you snore loudly? (louder than talking or loud enough to be heard\nthrough closed doors)?\n\n
\nHas anyone observed you stop breathing during your sleep?\n\n
\nDo you have or are you being treated for high blood pressure?\n\n
\nHow often in the past 4 weeks did you have days in which you\nexperienced little or no pleasure in most of your activities?\n \n\n
\nyou 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?\n\n
\nyou were so irritable that you shouted at people or started fights or arguments?\n\n
\nyou felt much more self-confident than usual?\n\n
\nyou got much less sleep than usual and found you didn't really miss it?\n\n
\nyou were much more talkative or spoke faster than usual?\n\n
\nthoughts raced through your head or you couldn't slow your mind down?\n\n
\nyou were so easily distracted by things around you that you had trouble concentrating or staying on track?\n\n
\nyou had much more energy than usual?\n\n
\nyou were much more active or did many more things than usual?\n\n
\nHow often in the past 4 weeks has your appetite been either less\nthan usual or greater than usual?\n \n\n
\nyou were much more social or outgoing than usual? For example, you telephoned friends in the middle of the night.\n\n
\nyou were much more interested in sex than usual?\n\n
\nyou did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?\n\n
\nspending money got you or your family into trouble?\n\n
\nIf you answered YES to more than one of the above, have several of these ever happened during the same period of time?\n\n
\nHow much of a problem did any of these cause you, like being unable to work; having family, money, or legal troubles; or getting into arguments or fights?\n\n
\nI have tried everything that people have recommended to manage my pain and nothing helps.\n\n
\nMy pain is a medical problem and I should be dealing with physicians about it.\n\n
\nEverybody I speak with tells me that I have to learn to live with my pain, but I don't see why I should have to.\n\n
\nI still think despite what doctors tell me, there must be some surgical procedure or medication that would get rid of my pain.\n\n
\nIn the past 4 weeks, have you gained or lost weight without\ntrying to?\n \n\n
\nThe best thing I can do is find a doctor who can figure out how to get rid of my pain once and for all.\n\n
\nWhy can't someone just do something to take away my pain?\n\n
\nAll of this talk about how to cope better is a waste of my time.\n\n
\nI have been thinking that the way I cope with my pain could improve.\n\n
\nI have recently realized that there is no medical cure for my pain condition, so I want to learn some ways to cope with it.\n\n
\nEven if my pain doesn't go away, I am ready to start changing how I deal with it.\n\n
\nI realize now that it's time for me to come up with a better plan to cope with my pain problem.\n\n
\nI am beginning to wonder if I need to get some help to cope with my pain problem.\n\n
\nI have recently figured out that it's up to me to deal better with my pain.\n\n
\nI have recently come to the conclusion that it's time for me to change how I cope with my pain.\n\n
\nHow often in the past 4 weeks, have you had difficulty sleeping\nor trouble with sleeping too much?\n \n\n
\nI'm starting to wonder whether it's up to me to manage my pain rather than relying on physicians.\n\n
\nI have been thinking that doctors can only help so much in managing my pain and that the rest is up to me.\n\n
\nI have been wondering if there is something I could do to manage my pain better.\n\n
\nI am developing new ways to cope with my pain.\n\n
\nI have started to come up with strategies to help myself control my pain.\n\n
\nI'm getting help learning some strategies for coping better with my pain.\n\n
\nI am learning to help myself control my pain without doctors.\n\n
\nI am testing out some coping skills to manage my pain better.\n\n
\nI am learning ways to control my pain other than with medications or surgery.\n\n
\nIn general, how satisfied are you with your relationship?\n\n
\nIn the past 4 weeks, has your physical activity been slowed down\nor speeded up so much that people who know you could notice?\n \n\n
\nI have learned some good ways to keep my pain problem from interfering with my life.\n\n
\nWhen my pain flares up, I find myself automatically using coping strategies that have worked in the past, such as relaxation exercise or mental distraction.\n\n
\nI am using some strategies that help me better deal with my pain problem on a day-to-day basis.\n\n
\nI use what I have learned to help keep my pain under control.\n\n
\nI am currently using some suggestions people have made about how to live with my pain problem.\n\n
\nI have incorporated strategies for dealing with my pain into my everyday life.\n\n
\nI have made a lot of progress in coping with my pain.\n\n
\nIn the last month, how often have you been upset because of something that happened unexpectedly?\n\n
\nIn the last month, how often have you felt that you were unable to control the important things in your life?\n\n
\nIn the last month, how often have you felt nervous and stressed?\n\n
\nIn the past 4 weeks, have you often felt more tired out or less\nenergetic than usual?\n \n\n
\nIn the last month, how often have you felt confident about your ability to handle your personal problems?\n\n
\nIn the last month, how often have you felt that things were going your way?\n\n
\nIn the last month, how often have you found that you could not cope with all the things that you had to do?\n\n
\nIn the last month, how often have you been able to control irritations in your life?\n\n
\nIn the last month, how often have you felt that you were on top of things?\n\n
\nIn the last month, how often have you been angered because of things that were outside of your control?\n\n
\nIn the last month, how often have you felt difficulties were piling up so high that you could not overcome them?\n\n
\nIs there evidence of an acute change in mental status from the patient's baseline?\n\n
\nDid the patient have difficulty focusing attention (for example, being easily distractible or having difficulty keeping track of what was being said)?\n\n
\n(If present or abnormal) Did this behavior fluctuate during the interview (that is, tend to come-and-go or increase and decrease in severity)?\n\n
\nHow often in the past 4 weeks have you felt worthless or been\nbothered by feelings of guilt?\n \n\n
\n(If present or abnormal) Please describe this behavior.\n\n
\nWas the patient's thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable, switching from subject to subject?\n\n
\nOverall, how would you rate this patient's level of consciousness?\n\n
\nWas the patient disoriented at any time during the interview, such as thinking that he or she was somewhere other than the hospital, using the wrong bed, or misjudging the time of day?\n\n
\nDid the patient demonstrate any memory problems during the interview, such as inability to remember events in the hospital or difficulty remembering instructions?\n\n
\nDid the patient have any evidence of perceptual disturbances, such as hallucinations, illusions, or misinterpretations (for example, thinking something was moving when it was not)?\n\n
\nAt any time during the interview, did the patient have an unusually increased level of motor activity, such as restlessness, picking at bedclothes, tapping fingers, or making frequent, sudden changes \nin position?\n\n\n
\nAt any time during the interview, did the patient have an unusually decreased level of motor activity, such as sluggishness, staring into space, staying in one position for a long time, or moving \nvery slowly?\n\n\n
\nI need 8 hours of sleep to feel refreshed and function well during the day.\n\n
\nIn the past 4 weeks, have you often had trouble thinking,\nconcentrating, or making decisions?\n \n\n
\nWhen I do not get the proper amount of sleep on a given night, I need to catch up on the next day by napping or on the next night by sleeping longer.\n\n
\nI am concerned that chronic insomnia may have serious consequences for my physical health.\n\n
\nI am worried that I may lose control over my abilities to sleep.\n\n
\nAfter a poor night's sleep, I know that it will interfere with my daily activities on the next day.\n\n
\nIn order to be alert and function well during the day, I am better off taking a sleeping pill rather than having a poor night's sleep.\n\n
\nWhen I feel irritable, depressed, or anxious during the day, it is mostly because I did not sleep well the night before.\n\n
\nWhen I sleep poorly on one night, I know that it will disturb my sleep schedule for the whole week.\n\n
\nWithout an adequate night's sleep, I can hardly function the next day.\n\n
\nI can't ever predict whether I will have a good or poor night's sleep.\n\n
\nI have little ability to manage the negative consequences of disturbed sleep.\n\n
\nWhat's wrong with me?\n\n
\nHow often have you thought about death or suicide in the past 4 weeks?\n \n\n
\nWhen I feel tired, have no energy, or just seem not to function well during the day, it is generally because I did not sleep well the night before.\n\n
\nI believe that insomnia is essentially a result of a chemical imbalance.\n\n
\nI feel that insomnia is ruining my ability to enjoy life and prevents me from doing what I want.\n\n
\nMedication is probably the only solution to sleeplessness.\n\n
\nI avoid or cancel obligations (social, family, occupational) after a poor night's sleep.\n\n
\nHow would you rate your quality of life?\n\n
\nHow satisfied are you with your health?\n\n
\nTo what extent do you feel that physical pain prevents you from doing what you need to do?\n\n
\nHow much do you need any medical treatment to function in your daily life?\n\n
\nHow much do you enjoy life?\n\n
\nIn the past 4 weeks, have you thought a lot about a specific\nway to commit suicide?\n\n
\nTo what extent do you feel your life to be meaningful?\n\n
\nHow well are you able to concentrate?\n\n
\nHow safe do you feel in your daily life?\n\n
\nHow healthy is your physical environment?\n\n
\nDo you have enough energy for everyday life?\n\n
\nAre you able to accept your bodily appearance?\n\n
\nHave you enough money to meet your needs?\n\n
\nHow available to you is the information that you need in your day-to-day life?\n\n
\nTo what extent do you have the opportunity for leisure activities?\n\n
\nHow well are you able to get around?\n\n
\nIn the past year, have you had 2 weeks or\nmore during which you felt sad, blue, or\ndepressed; or when you lost all interest\nor pleasure in things that you usually\ncared about or enjoyed?\n\n
\nHow satisfied are you with your sleep?\n\n
\nHow satisfied are you with your ability to perform your daily living activities?\n\n
\nHow satisfied are you with your capacity for work?\n\n
\nHow satisfied are you with yourself?\n\n
\nHow satisfied are you with your personal relationships?\n\n
\nHow satisfied are you with your sex life?\n\n
\nHow satisfied are you with the support you get from your friends?\n\n
\nHow satisfied are you with the conditions of your living place?\n\n
\nHow satisfied are you with your access to health services?\n\n
\nHow satisfied are you with your transport?\n\n
\nHave you had 2 years or more in your life\nwhen you felt depressed or sad most days,\neven if you felt okay sometimes?\n\n
\nHow often do you have negative feelings such as blue mood, despair, anxiety, depression?\n\n
\nDo you have any comments about the assessment? Type "none" or "NA" for no comment.\n\n
\nDifficulty falling asleep.\n\n
\nDifficulty staying asleep.\n\n
\nProblems waking up too early.\n\n
\nHow SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern?\n\n
\nHow NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life?\n\n
\nHow WORRIED/DISTRESSED are you about your current sleep problem?\n\n
\nTo what extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g. daytime fatigue, mood, ability to function at work/daily chores, concentration, memory, mood, etc.) \nCURRENTLY?\n\n\n
\nI feel threatened and afraid when I have an important problem to solve.\n\n
\nHave you felt depressed or sad much of the\ntime in the past year?\n\n
\nWhen making decisions, I do not evaluate all my options carefully enough.\n\n
\nI feel nervous and unsure of myself when I have an important decision to make.\n\n
\nWhen my first efforts to solve a problem fail, I know if I persist and do not give up too easily, I will be able to eventually find a good solution.\n\n
\nWhen I have a problem, I try to see it as a challenge, or opportunity to benefit in some positive way from having the problem.\n\n
\nI wait to see if a problem will resolve itself first, before trying to solve it myself.\n\n
\nWhen my first efforts to solve a problem fail, I get very frustrated.\n\n
\nWhen I am faced with a difficult problem, I doubt that I will be able to solve it on my own no matter how hard I try.\n\n
\nWhenever I have a problem, I believe that it can be solved.\n\n
\nI go out of my way to avoid having to deal with problems in my life.\n\n
\nDifficult problems make me very upset.\n\n
\nWhich of the following best describes your racial background?\n \n\n
\nWhen I have a decision to make, I try to predict the positive and negative consequences of each option.\n\n
\nWhen problems occur in my life, I like to deal with them as soon as possible.\n\n
\nWhen I am trying to solve a problem, I go with the first good idea that comes to mind.\n\n
\nWhen I am faced with a difficult problem, I believe that I will be able to solve it on my own if I try hard enough.\n\n
\nWhen I have a problem to solve, one of the first things I do is get as many facts about the problem as possible.\n\n
\nWhen a problem occurs in my life, I put off trying to solve it for as long as possible.\n\n
\nI spend more time avoiding my problems than solving them.\n\n
\nBefore I try to solve a problem, I set a specific goal so that I know exactly what I want to accomplish.\n\n
\nWhen I have a decision to make, I do not take the time to consider the pros and cons of each option.\n\n
\nAfter caring out a solution to a problem, I try to evaluate as carefully as possible how much the situation has changed for the better.\n\n
\nAre you of Spanish or Hispanic origin or ancestry?\n\n
\nI put off solving problems until it is too late to do anything about them.\n\n
\nWhen I am trying to solve a problem, I think of as many options as possible until I cannot come up with any more ideas.\n\n
\nWhen making decisions, I go with my "gut feeling" without thinking too much about the consequences of each option.\n\n
\nI am too impulsive when it comes to making decisions.\n\n
\nOverall, how would you rate the RLS discomfort in your legs or arms?\n\n
\nOverall, how would you rate the need to move around because of your RLS symptoms?\n\n
\nOverall, how much relief of your RLS arm or leg discomfort did you get from moving around?\n\n
\nHow severe was your sleep disturbance due to your RLS symptoms?\n\n
\nHow severe was your tiredness or sleepiness during the day due to your RLS symptoms?\n\n
\nHow severe was your RLS as a whole?\n\n
\nWhich of the following best describes your current marital status?\n \n\n
\nHow often did you get RLS symptoms?\n\n
\nWhen you had RLS symptoms, how severe were they on average?\n\n
\nOverall, how severe was the impact of your RLS symptoms on your ability to carry out your daily affairs, for example, carrying out a satisfactory family, home, social, school or work life?\n\n
\nHow severe was your mood disturbance due to your RLS symptoms - for example, angry, depressed, sad, anxious or irritable?\n\n
\nConsidering only your own "feeling best" rhythm, at what time would you get up if you were entirely free to plan your day?\n\n
\nConsidering only your own "feeling best" rhythm, at what time would you go to bed if you were entirely free to plan your evening?\n\n
\nAssuming normal circumstances, how easy do you find getting up in the morning?\n\n
\nHow alert do you feel after the first half hour after having awakened in the morning?\n\n
\nDuring the first half hour after having awakened in the morning, how tired do you feel?\n\n
\nYou have decided to engage in some physical exercise. A friend suggests that you do this one hour twice a week and the best time for him is 7:00-8:00 am. Bearing in mind nothing else but your \n"feeling best" rhythm, how do you think you would perform?\n\n\n
\nWhat is the highest grade you completed in school?\n \n\n
\nAt what time in the evening do you feel tired and as a result, in need of sleep?\n\n
\nYou wish to be at your peak performance for a two hour test, which will be mentally exhausting. You are entirely free to plan your day, and considering only your own "feeling best" rhythm, which ONE \nof the four testing times would you choose?\n\n\n
\nOne hears about "morning" and "evening" type people. Which ONE of these types do you consider yourself to be?\n\n
\nWhen would you prefer to rise (provided you have a full day's work - 8 hours) if you were totally free to arrange your time?\n\n
\nIf you always had to rise at 6:00 am, what do you think it would be like?\n\n
\nHow long a time does it usually take before you "recover your senses" in the morning after rising from a night's sleep?\n\n
\nPlease indicate to what extent you are a morning or an evening active individual?\n\n
\nDid you have a lot of energy?\n\n
\nHave you felt downhearted and low?\n\n
\nDriving (or other transport)?\n\n
\nHow many adults other than yourself live in your household?\n \n\n
\nHow much do your work limitations bother you?\n\n
\nHow much do your social limitations bother you?\n\n
\nHow much do your memory difficulties bother you?\n\n
\nHow much do physical effects of antiepileptic drugs bother you?\n\n
\nHow much do psychological effects of antiepileptic drugs bother you?\n\n
\nHow afraid are you of having a seizure during the next 4 weeks?\n\n
\nHow has your QUALITY OF LIFE been during the past 4 weeks (that is, how have things been going for you)?\n\n
\nIs there any indication that the person engaged in self-directed violent behavior, either preparatory or potentially harmful?\n\n
\nIs there any indication that the person had self-directed violence related thoughts?\n\n
\nWere/Are the thoughts suicidal?\n\n
\nI wish I were somewhere else.\n\n
\nHow many children live in your household?\n \n\n
\nDid the behavior involve any injury?\n\n
\nWas the injury fatal?\n\n
\nWas the behavior preparatory only?\n\n
\nWas the behavior interrupted by self or other(s)?\n\n
\nIs there evidence of suicidal intent?\n\n
\nDate and Time of event:\n\n
\nBrief description of event:\n\n
\nLocation of event::\n\n
\nVeteran status at time of event:\n\n
\nVeteran status following the event:\n\n
\nWhich of the following categories best describes your household's\ntotal income before taxes last year? Please include income from\nall sources such as salaries and wages, Social Security, retirement\nIncome, investments, and other sources.\n \n\n
\nHospitalized at:\n\n
\nMethod of information:\n\n
\nSource of information:\n\n
\nSpecify "Other"\n\n
\nName and phone of source:\n\n
\nLast Pain Score:\n\n
\nDid the veteran have access to firearms?\n\n
\nFamily and other supports available at time of event:\n\n
\nOther support:\n\n
\nTreatment plan changes implemented due to the event:\n\n
\nDoes the patient currently have:\n \n\n
\nDescribe / Other\n\n
\nPast 10 clinic visits:\n\n
\nVeteran was receiving treatment in the following area(s) at the time of this event:\n\n
\nName any specialty clinic(s) veteran was receiving treatment at time of this event (if none, type "None"):\n\n
\nPrimary Care Provider:\n\n
\nCase Manager / Therapist:\n\n
\nProvider prescribing psychiatric medications:\n\n
\nActive Problem List:\n\n
\nInpatient unit at time of event:\n\n
\nInpatient status at time of event:\n\n
\nDoes this patient:\nread and write English?\n\n
\nBrief Plan or Disposition (Check all that apply):\n\n
\nAny other plan or disposition not listed above? (If none, type "None")\n\n
\nMy relationship is boring vs. interesting:\n\n
\nMy relationship is bad vs. good:\n\n
\nMy relationship is empty vs. full:\n\n
\nMy relationship is fragile vs. sturdy:\n\n
\nMy relationship is discouraging vs. hopeful:\n\n
\nPlanning family activities is difficult because we misunderstand each other.\n\n
\nWe resolve most everyday problems around the house.\n\n
\nHave sufficient cognitive function to report about the last 6 months?\n\n
\nWhen someone is upset the others know why.\n\n
\nWhen you ask someone to do something, you have to check that they did it.\n\n
\nIf someone is in trouble, the others become too involved.\n\n
\nIn times of crisis we can turn to each other for support.\n\n
\nWe don't know what to do when an emergency comes up.\n\n
\nWe sometimes run out of things that we need.\n\n
\nWe are reluctant to show our affection for each other.\n\n
\nWe make sure members meet their family responsibilities.\n\n
\nWe cannot talk to each other about the sadness we feel.\n\n
\nWe usually act on our decisions regarding problems.\n\n
\nDuring the past 2 weeks, has the patient experienced nearly every day:\nDepressed mood most of the day by their own report\nor the report of others?\n\n
\nYou only get the interest of others when something is important to them.\n\n
\nYou can't tell how a person is feeling from what they are saying.\n\n
\nFamily tasks don't get spread around enough.\n\n
\nIndividuals are accepted for what they are.\n\n
\nYou can easily get away with breaking the rules.\n\n
\nPeople come right out and say things instead of hinting at them.\n\n
\nSome of us just don't respond emotionally.\n\n
\nWe know what to do in an emergency.\n\n
\nWe avoid discussing our fears and concerns.\n\n
\nIt is difficult to talk to each other about tender feelings.\n\n
\nMarkedly diminished interest or pleasure in all, or almost\nall, activities most of the day?\n\n
\nWe have trouble meeting our bills.\n\n
\nAfter our family tries to solve a problem, we usually discuss whether it worked or not.\n\n
\nWe are too self-centered.\n\n
\nWe can express feelings to each other.\n\n
\nWe have no clear expectations about toilet habits.\n\n
\nWe do not show our love for each other.\n\n
\nWe talk to people directly rather than through go-betweens.\n\n
\nEach of us has particular duties and responsibilities.\n\n
\nThere are lots of bad feelings in the family.\n\n
\nWe have rules about hitting people.\n\n
\nDecrease or increase in appetite or significant weight\nloss or weight gain when not dieting?\n\n
\nWe get involved with each other only when something interests us.\n\n
\nThere's little time to explore personal interests.\n\n
\nWe often don't say what we mean.\n\n
\nWe feel accepted for what we are.\n\n
\nWe show interest in each other when we can get something out of it personally.\n\n
\nWe resolve most emotional upsets that come up.\n\n
\nTenderness takes second place to other things in our family.\n\n
\nWe discuss who is to do household jobs.\n\n
\nMaking decisions is a problem for our family.\n\n
\nOur family shows interest in each other only when they can get something out of it.\n\n
\nInsomnia or hypersomnia?\n\n
\nWe are frank with each other.\n\n
\nWe don't hold to any rules or standards.\n\n
\nIf people are asked to do something, they need reminding.\n\n
\nWe are able to make decisions about how to solve problems.\n\n
\nIf the rules are broken, we don't know what to expect.\n\n
\nAnything goes in our family.\n\n
\nWe express tenderness.\n\n
\nWe confront problems involving feelings.\n\n
\nWe don't get along well together.\n\n
\nWe don't talk to each other when we are angry.\n\n
\nPsychomotor agitation or retardation by their own report or\nthe report of others?\n\n
\nWe are generally dissatisfied with the family duties assigned to us.\n\n
\nEven though we mean well, we intrude too much into each others lives.\n\n
\nThere are rules about dangerous situations.\n\n
\nWe confide in each other.\n\n
\nWe cry openly.\n\n
\nWe don't have reasonable transport.\n\n
\nWhen we don't like what someone has done, we tell them.\n\n
\nWe try to think of different ways to solve problems.\n\n
\nPlease indicate what stage of therapy you are at present\n\n
\nProgress toward goals: In the past 3 months, you have come up with...\n\n
\nI can't get things together.\n\n
\nFatigue or loss of energy?\n\n
\nKnowledge: How much do you feel like you know about symptoms, treatment, coping strategies (coping methods), and medication?\n\n
\nInvolvement of family and friends in my mental health treatment: How much are family members, friends, boyfriends or girlfriends, and other people who are important to you (outside the mental health \nagency) involved in your treatment?\n\n\n
\nContact with people outside of your family: In a normal week, how many times do you talk to someone outside of your family (a friend, co-worker, classmate, roommate, etc.)?\n\n
\nTime in structured roles: How much time do you spend working, volunteering, being a student, being a parent, taking care of someone else or someone else's house or apartment? That is, how much time \ndo you spend doing activities that are expected of you for or with another person? (This would not include self-care or personal home maintenance.)\n\n\n
\nSymptom distress: How much do symptoms bother you?\n\n
\nImpairment of functioning: How much do symptoms get in the way of your doing things that you would like to do or need to do?\n\n
\nRelapse Prevention Planning: Which of the following would best describe what you know and have done in order to not have a relapse?\n\n
\nRelapse of symptoms: When is the last time you had a relapse of symptoms (that is, when symptoms have gotten much worse)?\n\n
\nPsychiatric hospitalizations: When is the last time you have been hospitalized for mental health or substance abuse reasons?\n\n
\nCoping: How well do you feel that you are coping with your mental or emotional illness from day to day?\n\n
\nFeelings of worthlessness or excessive or inappropriate guilt?\n\n
\nInvolvement with self-help activities: How involved are you in consumer run services, peer support groups, Alcoholics Anonymous, drop-in centers, WRAP (Wellness Recovery Action Plan), or other \nsimilar self-help programs?\n\n\n
\nUsing medication effectively: How often do you take your medication as prescribed?\n\n
\nFunctioning affected by alcohol use: Drinking can interfere with functioning when it contributes to conflict in relationships; to money, housing, and legal concerns; to difficulty showing up at \nappointments or paying attention during them; or to increased symptoms. Over the past 3 months, how much did drinking get in the way of your functioning?\n\n\n
\nFunctioning affected by drug use. Using street drugs and misusing prescription or over-the-counter medication can interfere with functioning when it contributes to conflict in relationships; to \nmoney, housing, and legal concerns; to difficulty showing up at appointments or paying attention during them; or to increased symptoms. Over the past 3 months, how much did drug use get in the way of \n your functioning?\n\n\n
\nConcerns with contamination (dirt, germs, chemicals, radiation) or acquiring a serious illness such as AIDS?\n\n
\nOverconcern with keeping objects (clothing, tools, etc) in perfect order or arranged exactly?\n\n
\nImages of death or horrible events?\n\n
\nPersonally unacceptable religious or sexual thoughts?\n\n
\nFire, burglary or flooding of the house?\n\n
\nAccidentally hitting a pedestrian with your car or letting it roll down a hill?\n\n
\nDiminished ability to think or concentrate, or indecisiveness?\n\n
\nSpreading an illness (giving someone AIDS)?\n\n
\nLosing something valuable?\n\n
\nHarm coming to a loved one because you weren't careful enough?\n\n
\nPhysically harming a loved one, pushing a stranger in front of a bus, steering your car into oncoming traffic; inappropriate sexual contact; or poisoning dinner guests?\n\n
\nExcessive or ritualized washing, cleaning or grooming?\n\n
\nChecking light switches, water faucets, the stove, door locks or the emergency brake?\n\n
\nCounting, arranging; evening-up behaviors (making sure socks are at same height)?\n\n
\nCollecting useless objects or inspecting the garbage before it is thrown out?\n\n
\nRepeating routine actions (in/out of chair, going through doorway, relighting cigarette) a certain number of times or until it feels just right?\n\n
\nNeeding to touch objects or people?\n\n
\nRecurrent thoughts of death, recurrent suicidal ideation with or\nwithout a specific plan, or suicide attempt?\n\n
\nUnnecessary rereading or rewriting; reopening envelopes before they are mailed?\n\n
\nExamining your body for signs of illness?\n\n
\nAvoiding colors ("red" means blood), numbers ("13" is unlucky) or names (those that start with "D" signify death) that are associated with dreaded events or unpleasant thoughts?\n\n\nNeeding to "confess" or repeatedly asking for reassurance that you said or did something correctly?\n\n
\nOn average, how much time is occupied by these thoughts or behaviors each day?\n\n
\nHow much distress do they cause you?\n\n
\nHow hard is it for you to control them?\n\n
\nHow much do they cause you to avoid doing anything, going anyplace or being with anyone?\n\n
\nHow much do they interfere with school, work or your social or family life?\n\n
\nHas substance use initiated and maintained the depression?\n \n\n
\nRepeated, disturbing, and unwanted memories of the stressful experience?\n\n
\nRepeated, disturbing dreams of the stressful experience?\n\n
\nSuddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?\n\n
\nFeeling very upset when something reminded you of the stressful experience?\n\n
\nHaving strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?\n\n
\nAvoiding memories, thoughts, or feelings related to the stressful experience?\n\n
\nAvoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?\n\n
\nTrouble remembering important parts of the stressful experience?\n\n
\nHaving 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 \n is completely dangerous)?\n\n\n
\nHas an organic factor initiated and maintained the depression?\n \n\n
\nBlaming yourself or someone else for the stressful experience or what happened after it?\n\n
\nHaving strong negative feelings such as fear, horror, anger, guilt, or shame?\n\n
\nLoss of interest in activities that you used to enjoy?\n\n
\nFeeling distant or cut off from other people?\n\n
\nTrouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?\n\n
\nIrritable behavior, angry outbursts, or acting aggressively?\n\n
\nTaking too many risks or doing things that could cause you harm?\n\n
\nBeing "superalert" or watchful or on guard?\n\n
\nFeeling jumpy or easily startled?\n\n
\nHaving difficulty concentrating?\n\n
\nIs the depression a normal reaction to the death of a loved one?\n \n\n
\nTrouble falling or staying asleep?\n\n
\nHow satisfied are you with the quality of your relationships with friends, family, and the other people in your life?\n\n
\nHow skilled are you at communicating with other people in your life?\n\n
\nHow satisfied are you with your involvement in community activities? Community activities include working, volunteering, being a student, or attending clubs and organizations.\n\n
\nHow skilled are you at interacting with others in community settings? Community settings include a work or volunteer job site, school, or clubs and organizations.\n\n
\nHow satisfied are you with your relationships with the people who provide your mental health services?\n\n
\nHow skilled are you at interacting with your mental health service providers?\n\n
\nHow would you rate your attendance for scheduled mental health appointments?\n\n
\nHow satisfied are you with your overall health and well-being?\n\n
\nHow skilled are you at managing your overall health and well-being?\n\n
\nDoes the patient have Schizophrenia, Schizophreniform Disorder,\nDelusional Disorder, or Psychotic Disorders?\n \n\n
\nTo be completed by the clinician at the end of the individual session:||What is the main goal that the Veteran would like to reach with the help of Social Skills Training?\n\n
\nHow satisfied are you with the quality of your relationships with friends, family, and the other people in your life?\n\n
\nHow skilled are you at communicating with other people in your life?\n\n
\nHow satisfied are you with your involvement in communtiy activities, which include working, volunteering, being a student, or attending clubs and organizations?\n\n
\nHow skilled are you at interacting with others in community settings? Community settings include a work or volunteer job site, school, or clubs and organizations.\n\n
\nHow satisfied are you with your relationships with the people who provide your mental health services?\n\n
\nHow skilled are you at interacting with your mental health service providers?\n\n
\nHow would you rate your attendance for scheduled mental health appointments?\n\n
\nHow satisfied are you with your overall health and well-being?\n\n
\nHow skilled are you at managing your overall health and well-being?\n\n
\nHas the patient ever demonstrated:\nA pattern of drug abuse that interferes with health,\nrelationships, or work?\n\n
\nThis is the main goal that you chose before you started attending Social Skills Training?\n\n
\nPlease rate your progress towards the recovery goal you identified at the start of Social Skills Training.\n\n
\nHow helpful was Social Skills Training in reaching your recovery goal?\n\n
\nHow helpful was Social Skills Training in improving your communication with friends, family, and the other people in your life?\n\n
\nHow helpful was Social Skills Training in improving your interactions with others in community settings?\n\n
\nHow helpful was Social Skills Training in improving your communication with mental health service providers?\n\n
\nHow helpful was Social Skills Training in improving your overall health and well-being?\n\n
\nI really want to make changes in my drinking.\n\n
\nSometimes I wonder if I am an alcoholic.\n\n
\nIf I don't change my drinking soon, my problems are going to get worse.\n\n
\nA pattern of alcohol use that interferes with health,\nrelationships, or work?\n\n
\nI have already started making some changes in my drinking.\n\n
\nI was drinking too much at one time, but I've managed to change my drinking.\n\n
\nSometimes I wonder if my drinking is hurting other people.\n\n
\nI am a problem drinker.\n\n
\nI'm not just thinking about changing my drinking, I'm already doing something about it.\n\n
\nI have already changed my drinking, and I am looking for ways to keep from slipping back to my old pattern.\n\n
\nI have serious problems with drinking.\n\n
\nSometimes I wonder if I am in control of my drinking.\n\n
\nMy drinking is causing a lot of harm.\n\n
\nI am actively doing things now to cut down or stop drinking.\n\n
\nI hate myself.\n\n
\nA manic episode?\n\n
\nI want help to keep from going back to the drinking problems that I had before.\n\n
\nI know that I have a drinking problem.\n\n
\nThere are times when I wonder if I drink too much.\n\n
\nI am an alcoholic.\n\n
\nI am working hard to change my drinking.\n\n
\nI have made some changes in my drinking, and I want some help to keep from going back to the way I used to drink.\n\n
\nI really want to make changes in my use of drugs.\n\n
\nSometimes I wonder if I am an addict.\n\n
\nIf I don't change my drug use soon, my problems are going to get worse.\n\n
\nI have already started making some changes in my use of drugs.\n\n
\nDelusions or hallucinations without mood symptoms?\n\n
\nI was using drugs too much at one time, but I've managed to change that.\n\n
\nSometimes I wonder if my drug use is hurting other people.\n\n
\nI have a drug problem.\n\n
\nI'm not just thinking about changing my drug use, I'm already doing something about it.\n\n
\nI have already changed my drug use, and I am looking for ways to keep from slipping back to my old pattern.\n\n
\nI have serious problems with drugs.\n\n
\nSometimes I wonder if I am in control of my drug use.\n\n
\nMy drug use is causing a lot of harm.\n\n
\nI am actively doing things now to cut down or stop my use of drugs.\n\n
\nI want help to keep from going back to the drug problems that I had before.\n\n
\nSymptoms that meet criteria for a diagnosis of PTSD?\n\n
\nI know that I have a drug problem.\n\n
\nThere are times when I wonder if I use drugs too much.\n\n
\nI am a drug addict.\n\n
\nI am working hard to change my drug use.\n\n
\nI have made some changes in my drug use, and I want some help to keep from going back to the way I used before.\n\n
\nAlcohol (for men, 5 or more drinks a day or for women, 4 or more drinks a day)\n\n
\nTobacco Products\n\n
\nPrescription Drugs for Non-Medical Reasons\n\n
\nIllegal Drugs\n\n
\nCannabis (marijuana, pot, grass, hash, etc.)\n\n
\nPlease check which, if any, of the following drugs the patient has\nregularly taken during the month before the visit. If the patient\nIs taking none of these drugs, please answer yes to 'none of the\nabove drugs'.\n \n \nreserpine\n\n
\nCocaine (coke, crack, etc.)\n\n
\nPrescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.)\n\n
\nMethamphetamine (speed, crystal meth, ice, etc.)\n\n
\nInhalants (nitrous oxide, glue, gas, paint thinner, etc.)\n\n
\nSedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium, Rohypnol, GHB, etc.)\n\n
\nHallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.)\n\n
\nStreet opioids (heroin, opium, etc.)\n\n
\nPrescription opioids (fentanyl, oxycodone [OxyContin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.)\n\n
\nIn the past three months, how often have you used cannabis (marijuana, pot, grass, hash, etc.)?\n\n
\nAnabolic steroids (testosterone)\n\n
\nIn the past three months, how often have you used cocaine (coke, crack, etc.)?\n\n
\nIn the past three months, how often have you used prescription stimulants (Ritalin, Dexedrine, Adderall, diet pills, etc.)?\n\n
\nIn the past three months, how often have you used methamphetamine (speed, crystal meth, etc.)?\n\n
\nIn the past three months, how often have you used inhalants (nitrous oxide, gas, paint thinner, etc.)?\n\n
\nIn the past three months, how often have you used sedatives or sleeping pills (Valium, Serepax, Ativan, Librium, Xanax, GHB, etc.)?\n\n
\nIn the past three months, how often have you used hallucinogens (LSD, acid, PCP, Special K, ecstasy, etc.)?\n\n
\nIn the past three months, how often have you used street opioids (heroin, opium, etc.)?\n\n
\nIn the past three months, how often have you used prescription opioids (fentanyl, oxycodone, [OxyContin], hydrocodone [Vicodin],methadone, buprenorphine, etc.)?\n\n
\nIn the past 3 months, how often have you had a strong desire or urge to use cannabis (marijuana, pot, grass, hash, etc.)?\n\n
\nGlucocorticoids (cortisone, dexamethesone, hydrocortisone,\nprednisone, triamcinolone)\n\n
\nIn the past 3 months, how often have you had a strong desire or urge to use cocaine (coke, crack, etc.)?\n\n
\nIn the past 3 months, how often have you had a strong desire or urge to use prescribed amphetamine type stimulants (Ritalin, Dexedrine, Adderall, diet pills, etc.)?\n\n
\nIn the past 3 months, how often have you had a strong desire or urge to use methamphetamine (speed, crystal meth, etc.)?\n\n
\nIn the past 3 months, how often have you had a strong desire or urge to use inhalants (nitrous oxide, gas, paint thinner, etc.)?\n\n
\nIn the past 3 months, how often have you had a strong desire or urge to use sedatives or sleeping pills (Valium, Serepax, Ativan, Librium, Xanax, GHB, etc.)?\n\n
\nIn the past 3 months, how often have you had a strong desire or urge to use hallucinogens (LSD, acid, PCP, Special K, ecstasy, etc.)?\n\n
\nIn the past 3 months, how often have you had a strong desire or urge to use street Opioids (heroin, opium, etc.)?\n\n
\nIn the past 3 months, how often have you had a strong desire or urge to use prescribed opioids (fentanyl, oxycodone [OxyContin], hydrocodone [Vicodin], methadone, buprenorphine, etc.)?\n\n
\nDuring the past 3 months, how often has your use of cannabis (marijuana, pot, grass, hash, etc.) led to health, social, legal or financial problems?\n\n
\nIndicate your feelings during the past week.\n \nI felt that I could not shake off the blues even with help from my family\nor friends.\n \n\n
\nDuring the past 3 months, how often has your use of cocaine (coke, crack, etc.) led to health, social, legal or financial problems?\n\n
\nDuring the past 3 months, how often has your use of prescribed amphetamine type stimulants (Ritalin, Dexedrine, Adderall, diet pills, etc.) led to health, social, legal or financial problems?\n\n
\nDuring the past 3 months, how often has your use of methamphetamine (speed, crystal meth, etc.) led to health, social, legal or financial problems?\n\n
\nDuring the past 3 months, how often has your use of inhalants (nitrous oxide, gas, paint thinner, etc.) led to health, social, legal or financial problems?\n\n
\nDuring the past 3 months, how often has your use of sedatives or sleeping pills (Valium, Serepax, Ativan, Librium, Xanax, GHB, etc.) led to health, social, legal or financial problems?\n\n
\nDuring the past 3 months, how often has your use of hallucinogens (LSD, acid, PCP, Special K, ecstasy, etc.) led to health, social, legal or financial problems?\n\n
\nDuring the past 3 months, how often has your use of street opioids (heroin, opium, etc.) led to health, social, legal or financial problems?\n\n
\nDuring the past 3 months, how often has your use of prescribed opioids (fentanyl, oxycodone [OxyContin], hydrocodone [Vicodin], methadone, buprenorphine, etc.) led to health, social, legal or \nfinancial problems?\n\n\n
\nDuring the past 3 months, how often have you failed to do what was normally expected of you because of your use of cannabis (marijuana, pot, grass, hash, etc.)?\n\n
\nIndicate your feelings during the past week.\n \nI felt depressed.\n \n\n
\nDuring the past 3 months, how often have you failed to do what was normally expected of you because of your use of cocaine (coke, crack, etc.)?\n\n
\nDuring the past 3 months, how often have you failed to do what was normally expected of you because of your use of prescribed amphetamine type stimulants (Ritalin, Dexedrine, Adderall, diet pills, \netc.)?\n\n\n
\nDuring the past 3 months, how often have you failed to do what was normally expected of you because of your use of methamphetamine (speed, crystal meth etc.)?\n\n
\nDuring the past 3 months, how often have you failed to do what was normally expected of you because of your use of inhalants (nitrous oxide, gas, paint thinner, etc.)?\n\n
\nDuring the past 3 months, how often have you failed to do what was normally expected of you because of your use of sedatives or sleeping pills (Valium, Serepax, Ativan, Librium, Xanax, GHB, etc.)?\n\n
\nDuring the past 3 months, how often have you failed to do what was normally expected of you because of your use of street Opioids (heroin, opium, etc.)?\n\n
\nDuring the past 3 months, how often have you failed to do what was normally expected of you because of your use of prescribed opioids (fentanyl, oxycodone [OxyContin], hydrocodone [Vicodin], \nmethadone, buprenorphine, etc.)?\n\n\n
\nHas a friend or relative or anyone else ever expressed concern about your use of cannabis (marijuana, pot, grass, hash, etc.)?\n\n
\nIndicate your feelings during the past week.\n \nI felt fearful.\n \n\n
\nHas a friend or relative or anyone else ever expressed concern about your use of cocaine (coke, crack, etc.)?\n\n
\nHas a friend or relative or anyone else ever expressed concern about your use of prescribed amphetamine type stimulants (Ritalin, Dexedrine, Adderall, diet pills, etc.)?\n\n
\nHas a friend or relative or anyone else ever expressed concern about your use of methamphetamine (speed, crystal meth, etc.)?\n\n
\nHas a friend or relative or anyone else ever expressed concern about your use of inhalants (nitrous oxide, gas, paint thinner, etc.)?\n\n
\nHas a friend or relative or anyone else ever expressed concern about your use of sedatives or sleeping pills (Valium, Serepax, Xanax, Ativan, Librium, GHB, etc.)?\n\n
\nHas a friend or relative or anyone else ever expressed concern about your use of hallucinogens (LSD, acid, PCP, Special K, ecstasy, etc.)?\n\n
\nHas a friend or relative or anyone else ever expressed concern about your use of street opioids (heroin, opium, etc.)?\n\n
\nHas a friend or relative or anyone else ever expressed concern about your use of prescribed opioids (fentanyl, oxycodone [OxyContin], hydrocodone [Vicodin], methadone, buprenorphine, etc.)?\n\n
\nHave you ever tried and failed to control, cut down or stop using cannabis (marijuana, pot, grass, hash, etc.)?\n\n
\nIndicate your feelings during the past week.\n \nMy sleep was restless.\n \n\n
\nHave you ever tried and failed to control, cut down or stop using cocaine (coke, crack, etc.)?\n\n
\nHave you ever tried and failed to control, cut down or stop using prescribed amphetamine type stimulants (Ritalin, Dexedrine, Adderall, diet pills, etc.)?\n\n
\nHave you ever tried and failed to control, cut down or stop using methamphetamine (speed, crystal meth, etc.)?\n\n
\nHave you ever tried and failed to control, cut down or stop using inhalants (nitrous oxide, gas, paint thinner, etc.)?\n\n
\nHave you ever tried and failed to control, cut down or stop using sedatives or sleeping pills (Valium, Serepax, Xanax, Ativan, Librium, GHB, etc.)?\n\n
\nHave you ever tried and failed to control, cut down or stop using hallucinogens (LSD, acid, PCP, Special K, ecstasy, etc.)?\n\n
\nHave you ever tried and failed to control, cut down or stop using street opioids (heroin, opium, etc.)?\n\n
\nHave you ever tried and failed to control, cut down or stop using prescribed opioids ( fentanyl, oxycodone [OxyContin], hydrocodone [Vicodin], methadone, buprenorphine, etc.)?\n\n
\nHave you ever used any drug by injection (NONMEDICAL USE ONLY)?\n\n
\nTrunk Movements\n \nNeck, shoulders, hips,\ne.g., rocking, twisting, squirming, pelvic gyrations. Include\ndiaphragmatic movements.\n \n\n
\nI'm worthless.\n\n
\nIndicate your feelings during the past week.\n \nI felt hopeless about the future.\n \n\n
\nIn the course of last week...It was hard for me to concentrate.\n\n
\nIn the course of last week...I felt helpless.\n\n
\nIn the course of last week...I was absent-minded and unable to remember what I was actually doing.\n\n
\nIn the course of last week...I felt disgust.\n\n
\nIn the course of last week...I thought of hurting myself.\n\n
\nIn the course of last week...I didn't trust other people.\n\n
\nIn the course of last week...I didn't believe in my right to live.\n\n
\nIn the course of last week...I was lonely.\n\n
\nIn the course of last week...I experienced stressful inner tension.\n\n
\nIn the course of last week...I had images that I was very much afraid of.\n\n
\nWhen working, I move at a steady pace.\n\n
\nIn the course of last week...I hated myself.\n\n
\nIn the course of last week...I wanted to punish myself.\n\n
\nIn the course of last week...I suffered from shame.\n\n
\nIn the course of last week...My mood rapidly cycled in terms of anxiety, anger, and depression.\n\n
\nIn the course of last week...I suffered from voices and noises from inside or outside my head.\n\n
\nIn the course of last week...Criticism had a devastating effect on me.\n\n
\nIn the course of last week...I felt vulnerable.\n\n
\nIn the course of last week...The idea of death had a certain fascination for me.\n\n
\nIn the course of last week...Everything seemed senseless to me.\n\n
\nIn the course of last week...I was afraid of losing control.\n\n
\nIf I watch someone do something that I know is wrong, I will forget it\nbecause it does not affect me.\n\n
\nIn the course of last week...I felt disgusted by myself.\n\n
\nIn the course of last week...I felt as if I was far away from myself.\n\n
\nIn the course of last week...I felt worthless.\n\n
\nI am clear about my feelings.\n\n
\nI pay attention to how I feel.\n\n
\nI experience my emotions as overwhelming and out of control.\n\n
\nI have no idea how I am feeling.\n\n
\nI have difficulty making sense out of my feelings.\n\n
\nI am attentive to my feelings.\n\n
\nI know exactly how I am feeling.\n\n
\nI believe that safety is important.\n\n
\nI care about what I am feeling.\n\n
\nI am confused about how I feel.\n\n
\nWhen I'm upset, I acknowledge my emotions.\n\n
\nWhen I'm upset, I become angry with myself for feeling that way.\n\n
\nWhen I'm upset, I become embarrassed for feeling that way.\n\n
\nWhen I'm upset, I have difficulty getting work done.\n\n
\nWhen I'm upset, I become out of control.\n\n
\nWhen I'm upset, I believe that I will remain that way for a long time.\n\n
\nWhen I'm upset, I believe that I'll end up feeling very depressed.\n\n
\nWhen I'm upset, I believe that my feelings are valid and important.\n\n
\nI like to work around machinery.\n\n
\nWhen I'm upset, I have difficulty focusing on other things.\n\n
\nWhen I'm upset, I feel out of control.\n\n
\nWhen I'm upset, I can still get things done.\n\n
\nWhen I'm upset, I feel ashamed with myself for feeling that way.\n\n
\nWhen I'm upset, I know that I can find a way to eventually feel better.\n\n
\nWhen I'm upset, I feel like I am weak.\n\n
\nWhen I'm upset, I feel like I can remain in control of my behaviors.\n\n
\nWhen I'm upset, I feel guilty for feeling that way.\n\n
\nWhen I'm upset, I have difficulty concentrating.\n\n
\nWhen I'm upset, I have difficulty controlling my behaviors.\n\n
\nPeople can depend on me.\n\n
\nWhen I'm upset, I believe there is nothing I can do to make myself feel better.\n\n
\nWhen I'm upset, I become irritated with myself for feeling that way.\n\n
\nWhen I'm upset, I start to feel very bad about myself.\n\n
\nWhen I'm upset, I believe that wallowing in it is all I can do.\n\n
\nWhen I'm upset, I lose control over my behaviors.\n\n
\nWhen I'm upset, I have difficulty thinking about anything else.\n\n
\nWhen I'm upset, I take time to figure out what I'm really feeling.\n\n
\nWhen I'm upset, it takes me a long time to feel better.\n\n
\nWhen I'm upset, my emotions feel overwhelming.\n\n
\nBATHING\n\n
\nI feel people are against me.\n\n
\nDRESSING\n\n
\nTOILETING\n\n
\nTRANSFER\n\n
\nCONTINENCE\n\n
\nFEEDING\n\n
\nTIME SPENT ON OBSESSIONS:\n\n
\nOBSESSION-FREE INTERVAL:\n\n
\nCONTROL OVER OBSESSIONS:\n\n
\nDISTRESS OF OBSESSIONS:\n\n
\nINTERFERENCE FROM OBSESSIONS:\n\n
\nI feel I could succeed at a job.\n\n
\nTIME SPENT ON COMPULSIONS:\n\n
\nRESISTANCE TO COMPULSIONS:\n\n
\nCONTROL OVER COMPULSIONS:\n\n
\nDISTRESS IF COMPULSIONS PREVENTED:\n\n
\nINTERFERENCE FROM COMPULSIONS:\n\n
\nINSIGHT:\n\n
\nExcessive concern with germs. Examples: AIDS or hepatitis.\n\n
\nExcessive concern with contaminants or chemicals. Examples: household cleansers, asbestos, radiation, pesticides and toxic waste.\n\n
\nConcern will harm others by spreading germs or contaminants. Examples: transfer germs from one object to another.\n\n
\nBothered by bodily waste or fluids. Examples: urine, feces, saliva or blood.\n\n
\nI like to look neat at work and away from work.\n\n
\nBothered by sticky substances or residues. Examples: adhesives, chalk dust, or grease.\n\n
\nExcessive concern with becoming pregnant or of making someone pregnant. Example: Woman afraid of conception if she swims in public pool.\n\n
\nConcerned with having an illness/disease. It is not always clear where to draw the line between somatic obsessions and somatic preoccupations of hypochondriasis. Factors that point to OCD are the\npresence of compulsions not limited to seeking reassurance.\n\n\n
\nFear of eating certain foods. Examples: excessive concern about risks of certain foods or food preparations, afraid will choke, food will change body chemistry. Distinguish from anorexia nervosa, in\nwhich concern is gaining weight.\n\n\n
\nFear might harm self or others because not careful enough. Examples: parked car rolling down hill, hit a pedestrian because not paying attention, customer gets injured because you gave him wrong\nmaterials or information.\n\n\n
\nFear might harm self or others on impulse. Examples: physically harming loved ones, stabbing or poisoning dinner guests, driving car into oncoming traffic, pushing stranger in front of a train. \nDistinguish from homicidal/suicidal intent.\n\n\n
\nFear of being responsible for terrible events. Examples: fire, burglary, flooding house, company going bankrupt, pipes freezing.\n\n
\nFear of blurting out obscenities or insults. Examples: shouting blasphemies in church, yelling fire in the movie theatre, writing obscenities in a business letter.\n\n
\nFear of doing something else embarrassing or inappropriate. Examples: sexual contact, spitting, taking off clothes in public, walking out with unpaid merchandise. Distinguish from social phobia.\n\n
\nViolent, horrific or repulsive images. Examples: intrusive and disturbing|images of car crashes or disfigured people. Distinguish from PTSD.\n\n
\nI am willing to study off the job in order to learn better how to\ndo my job.\n\n
\nExcessive concern with right/wrong or scrupulosity. Examples: worries about always doing "the right thing", unfounded worries about lying or cheating, didn't say prayers perfectly.\n\n
\nConcern with sacrilege or blasphemy. Examples: intrusive unacceptable|thoughts or images about God or religion. Concerns about adherence to religious|principles exceed those of religious peer group.\n\n
\nExcessive fears of Satan or demonic possession. Examples: fears triggered by "Red Devil" paint, sports teams with word devil in them, "666", pentangles.\n\n
\nForbidden or improper sexual thoughts or images. Examples: unwanted sexual thoughts about family members; images of unacceptable acts. Distinguish from paraphilias by asking about fantasy life.\n\n
\nExperiences unwanted sexual impulses. Examples: concerned that might "snap" and commit sexual violation. Feels as if hand is moving toward someone's private parts in the absence of arousal. \nDistinguish from paraphilias.\n\n\n
\nExcessive concerns about sexual orientation or gender identity. Examples: person repeatedly wonders if s/he is gay even though there is every reason to believes s/he is heterosexual. Distinguish from\n realistic issues around sexual or gender identity.\n\n\n
\nNeed for symmetry or exactness. Examples: certain things can't be touched or moved, clothes organized in closet alphabetically, bothered if pictures are not straight or canned goods not lined up.\n\n
\nPerfection in appearance or grooming. Examples: excessive concern about appearance of clothing, such as wrinkles, lint, loose threads; bothered if hair not parted exactly straight. Distinguish from\nOCPD.\n\n\n
\nFear of saying the wrong thing. Ex: patient may appear to have thought blocking because she is reviewing every possible interpretation of what she is about to say.\n\n
\nExcessively bothered by things not sounding "just right." Examples: readjusting stereo system until it sounds "just right"; asks family members to say things in just the right way, \nexcessively bothered by visual, auditory or somatic sensations of not being "just right".\n\n\n
\nI wish I could just disappear.\n\n
\nI am willing to get dirty when I work.\n\n
\nNeed to know or remember. Examples: needing to remember insignificant things like license plate numbers, bumper stickers, advertising slogans, names of actors.\n\n
\nNeed to hoard or save things. Examples: afraid that something valuable might be discarded with recycled newspapers even though all valuables are locked up in the safe. Distinguish from hobbies and\nconcern with objects of monetary or sentimental value.\n\n\n
\nFear of losing objects, information, or a person. Examples: otherwise rational man feared "losing" his 5-year old daughter when mailing envelopes; patient concerned that her "essence" would be left\nbehind when getting up from a chair.\n\n\n
\nMagical or superstitious fears. Examples: colors with special significance(black connected with death, red associated with blood and injury), black cats, stepping on side walk cracks, (un)lucky\nnumbers, getting pregnant from using a swimming pool.\n\n\n
\nIntrusive meaningless sounds, words, or music. Examples: songs or music with no special significance play over and over in one's mind like a broken record.\n\n
\nExcessive or ritualized hygiene. Examples: washes hands like surgeon scrubbing for the operating room, uses harsh detergents or very hot water; takes long ritualized showers; excessive tooth brushing\n or toilet routine.\n\n\n
\nCleaning of household items, inanimate objects or pets. Examples: floors kept so clean you can eat off them; prolonged vacuuming; daily thorough washing of car tires.\n\n
\nChecking locks, stove, appliances, emergency brake, faucets, etc. Examples: Checking that the doors are locked, stove is turned off, appliances unplugged.\n\n
\nChecking that nothing terrible did/will happen. Examples: makes sure that did not run over a pedestrian or did not leave cabinet open to poisonous substances, etc.\n\n
\nChecking that did not make mistake. Examples: homework, counting money, writing.\n\n
\nOnce I am given something to do, I want to complete it.\n\n
\nChecking tied to somatic obsessions. Examples: repeatedly probing groin to see if hernia is present; scrutinizing skin for signs of cancer; excessive exploration of lymph nodes. Distinguish from\nhypochondriasis.\n\n\n
\nNeed to repeat routine activities or boundary crossings. Examples: going through doorway, crossing state lines; may get stuck trying to enter a building, doing/undoing rituals, taking clothes on/off,\n may have to repeat a certain number of times.\n\n\n
\nEvening up behaviors. Examples: movement on right side up body has to be balanced with same movement on left side; adjusts height of stockings, tension of shoelaces, plucks or cuts hair to\nachieve symmetry. Distinguish latter from trichotillomania, in which hair is not pulled for a specific purpose.\n\n\n
\nRe-reading or re-writing. Examples: doubt information that just read, written letters must look perfect. Distinguish from dyslexia.\n\n
\nCounting compulsions. Examples: counting things like ceiling or floor tiles,|books in a bookcase, words in a sentence.\n\n
\nRitualized activity of daily living routines. Example: may have to put clothes on in a certain order, can only go to bed after following an elaborate series of steps, brush teeth in a ritualistic\nmanner.\n\n\n
\nExcessive religious rituals. Example: Repeating prayers or passages from the Bible an inordinate number of times.\n\n
\nOrdering or arranging compulsions. Example: straightening piles of stationary on a desktop or adjusting books in a bookcase.\n\n
\nRepeating what someone else has said. Example: word, phrase, or sound. Distinguish from echolalia of Tourette's Syndrome.\n\n
\nAsking for reassurance. Example: repeatedly asking spouse that they performed a routine correctly.\n\n
\nI respect people in authority.\n\n
\nRitualized eating behaviors. Ex: arrange or eat food in particular way or a specific order to avert a feared consequence other than gaining weight, as in anorexia nervosa.\n\n
\nSaves or collects useless items. Examples: piles up old newspapers, collects useless objects; house an become obstacle course with piles of trash. Distinguish from hobbies and concern with \n objects of monetary or sentimental value.\n\n\n
\nPicks up objects that most people would pass by. Examples: shards of broken glass, nails, pieces of paper with writing on them, staples.\n\n
\nExamines things that leave one's possession. Examples: sifts through garbage, ritual for washing off dinner plates to separate waste from accidentally lost items; won't throw out used disposable\nvacuum bags or the cat litter.\n\n\n
\nBuys many unneeded items. Examples: buys 20 umbrellas, 100 boxes of moth balls, etc. May not be symptom of OCD unless behavior is excessive (e.g., wastes a lot of money, or accumulates closets full\nof unnecessary items.).\n\n\n
\nNeed to tell, ask or confess things. Examples: confessing to sins or wrongs that didn't commit; feels must describe every detail so that nothing is left out; repeats the same question in different\nways to make sure it was understood.\n\n\n
\nNeed to do something until it feels "just right." Examples: adjusts car seat, straightens pictures, arranges papers on desk, doesn't let go of handshake, until feels an internal signal that its OK. \nHas no specific feared consequences in mind.\n\n\n
\nNeed to touch, tap, or rub. Examples: urge to touch or run finger along surfaces or edges, lightly touches other people; taps a certain number of times; rubs against soft materials. May be difficult\nto distinguish from complex motor tics of Tourette's.\n\n\n
\nStaring or blinking rituals. May be difficult to distinguish from motor tics of Tourettes Syndrome. If patient says has to blink a certain number or times or stare to neutralize an obsession,\n endorse as compulsions here.\n\n\n
\nSuperstitious behaviors. Examples: steps over sidewalk cracks, spits after having an unwanted thought; makes sure sentences never contain 13 words; makes sign of the cross before dialing\narea code for New Jersey.\n\n\n
\nI think children should work for their spending money.\n\n
\nMental rituals (other than checking or counting). Examples: silently reciting prayers or nonsense words to neutralize unwanted thoughts.\n\n
\nPervasive slowness. Extensive difficulty in starting, executing, and finishing a wide range of routines tasks. In extreme cases, may be unable to complete tasks without assistance and may\nbecome"paralyzed". Distinguish from psychomotor retardation secondary to depression or a primary movement disorder.\n\n\n
\nRitualized avoidance. Examples: plans course on roadmap to stay at least 1 mile from chemical factories.\n\n
\nActive measures to avoid contact with contaminants or other feared objects. Ex: wears rubber gloves, doesn't shake hands, has one clean and one dirty hand, won't go near anyone who seems to have a\ncut, won't sit down in a chair that has a red spot (possibly blood).\n\n\n
\nAvoids doing things, going places or being with someone because of obsessions.\n\n
\nAvoid contact with contaminated objects or people.\n\n
\nAvoid handling sharp or dangerous objects, or operating vehicles or machinery, out of concern might harm others.\n\n
\nAvoid contact with people, children or animals because of unwanted impulses.\n\n
\nAvoids talking to or writing to others for fear will say or write the wrong thing.\n\n
\nAvoids watching TV, listening to radio or reading newspaper to shield from disturbing information.\n\n
\nI can get along with people.\n\n
\nAvoids going shopping out of concern will buy extra items that aren't needed.\n\n
\nAvoids doing things, going places, or being with someone that would trigger time consuming or onerous rituals (e.g., washing, dressing, etc.).\n\n
\nAvoids reading or writing because it may bring on rituals (e.g., re-reading, re-writing).\n\n
\nObsession 1:\n\n
\nObsession 2:\n\n
\nObsession 3:\n\n
\nCompulsion 1:\n\n
\nCompulsion 2:\n\n
\nCompulsion 3:\n\n
\nAvoidance 1:\n\n
\nI enjoy taking on more responsibility.\n\n
\nAvoidance 2:\n\n
\nAvoidance 3:\n\n
\nI have been unhappy because of my drinking.\n\n
\nBecause of my drinking, I have not eaten properly.\n\n
\nI have failed to do what is expected of me because of my drinking.\n\n
\nI have felt guilty or ashamed because of my drinking.\n\n
\nI have taken foolish risks when I have been drinking.\n\n
\nWhen drinking, I have done impulsive things that I regretted later.\n\n
\nMy physical health has been harmed by my drinking.\n\n
\nI have had money problems because of my drinking.\n\n
\nI dislike most other people.\n\n
\nMy physical appearance has been harmed by my drinking.\n\n
\nMy family has been hurt by my drinking.\n\n
\nA friendship or close relationship has been damaged by my drinking.\n\n
\nMy drinking has gotten in the way of my growth as a person.\n\n
\nMy drinking has damaged my social life, popularity, or reputation.\n\n
\nI have spent too much or lost a lot of money because of my drinking.\n\n
\nI have had an accident while drinking or intoxicated.\n\n
\nIn the past three months, how often have you used other substances (as specified above)?\n\n
\nIn the past 3 months, how often have you had a strong desire or urge to use other substances (as specified above)?\n\n
\nI would like to be good at what I do.\n\n
\nDuring the past 3 months, how often has your use of other substances (as specified above) led to health, social, legal or financial problems?\n\n
\nDuring the past 3 months, how often have you failed to do what was normally expected of you because of your use of other substances (as specified above)?\n\n
\nHas a friend or relative or anyone else ever expressed concern about your use of other substances (as specified above)?\n\n
\nHave you ever tried and failed to control, cut down or stop using other substances (as specified above)?\n\n
\nOther\n\n
\nSpecify:\n\n
\nHow much does the state of your epilepsy-related quality of life distress you overall?\n\n
\nEnergy (tiredness)\n\n
\nEmotions (mood)\n\n
\nDaily activities (work, driving, social)\n\n
\nI would like to improve myself.\n\n
\nMental activity (thinking, concentrating, memory)\n\n
\nMedication effects (physical, mental)\n\n
\nWorry about fits (impact of fits)\n\n
\nOverall quality of life\n\n
\nOverall, how would you rate your quality of life?\n\n
\nDid you feel full of pep?\n\n
\nHave you been a very nervous person?\n\n
\nHave you felt so down in the dumps that nothing could cheer you up?\n\n
\nHave you felt calm and peaceful?\n\n
\nDid you have a lot of energy?\n\n
\nI am willing to work a 40 hour week.\n\n
\nHave you felt downhearted and blue?\n\n
\nDid you feel worn out?\n\n
\nHave you been a happy person?\n\n
\nDid you feel tired?\n\n
\nHave you worried about having another seizure?\n\n
\nDid you have difficulty reasoning and solving problems (such as making plans, making decisions, learning new things)?\n\n
\nHas your health limited your social activities (such as visiting with friends or close relatives)?\n\n
\nHow has the QUALITY OF YOUR LIFE been during the past 4 weeks (that is, how have things been going for you)?\n\n
\nIn the past 4 weeks, have you had any trouble with your memory?\n\n
\nTrouble remembering things people tell you?\n\n
\nWhat's the matter with me.\n\n
\nMy work is important to my employer.\n\n
\nTrouble concentrating or reading?\n\n
\nTrouble concentrating or doing one thing at a time?\n\n
\nLeisure time (such as hobbies, going out)?\n\n
\nDriving?\n\n
\nHow fearful are you of having a seizure during the next month?\n\n
\nDo you worry about hurting yourself during a seizure?\n\n
\nHow worried are you about embarrassment or other social problems resulting from having a seizure during the next month?\n\n
\nHow worried are you that medications you are taking will be bad for you if taken for a long time?\n\n
\nSeizures\n\n
\nMemory difficulties\n\n
\nI feel like I could develop a feeling of belonging to a company.\n\n
\nWork limitations\n\n
\nSocial limitations\n\n
\nPhysical effects of antiepileptic medication\n\n
\nMental effects of antiepileptic medication\n\n
\nHow good or bad do you think your health is?\n\n
\nComments (if any)\n\n
\nLittle interest or pleasure in doing things?\n\n
\nFeeling down, depressed, or hopeless?\n\n
\nFeeling more irritated, grouchy, or angry than usual?\n\n
\nSleeping less than usual, but still have a lot of energy?\n\n
\nI believe on being on time for work.\n\n
\nStarting lots more projects than usual or doing more risky things than usual?\n\n
\nFeeling nervous, anxious, frightened, worried, or on edge?\n\n
\nFeeling panic or being frightened?\n\n
\nAvoiding situations that make you anxious?\n\n
\nUnexplained aches and pains (e.g., head, back, joints, abdomen, legs)?\n\n
\nFeeling that your illnesses are not being taken seriously enough?\n\n
\nThoughts of actually hurting yourself?\n\n
\nHearing things other people couldn't hear, such as voices even when no one\nwas around?\n\n
\nFeeling that someone could hear your thoughts, or that you could hear what another person was thinking?\n\n
\nProblems with sleep that affected your sleep quality over all?\n\n
\nI am willing to get up early in the morning to come to work.\n\n
\nProblems with memory (e.g., learning new information) or with location (e.g., finding way home)?\n\n
\nUnpleasant thoughts, urges, or images that repeatedly enter your mind?\n\n
\nFeeling driven to perform certain behaviors or mental acts over and over again?\n\n
\nFeeling detached or distant from yourself, your body, your physical surroundings, or your memories?\n\n
\nNot knowing who you really are or what you want out of life?\n\n
\nNot feeling close to other people or enjoying your relationships with them?\n\n
\nDrinking at least 4 drinks of any kind of alcohol in a single day?\n\n
\nSmoking any cigarettes, a cigar, or pipe or using snuff or chewing tobacco?\n\n
\nUsing any of the following medicines ON YOUR OWN, that is, without a doctors prescription, in greater amounts or longer than prescribed: painkillers (like Vicodin), stimulants (like Ritalin or \nAdderall), sedatives or tranquilizers (like sleeping pills or Valium), or drugs marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like \nglue), or meth (like speed)?\n\n\n
\nConsidering only your own "feeling best" rhythm, at what time would you get up if you were entirely free to plan your day?\n\n
\nI want to support myself.\n\n
\nConsidering only your own "feeling best" rhythm, at what time would you go to bed if you were entirely free to plan your evening?\n\n
\nAssuming normal circumstances, how easy do you find getting up in the morning?\n\n
\nHow alert do you feel after the first half hour after having awakened in the morning?\n\n
\nDuring the first half hour after having awakened in the morning, how tired do you feel?\n\n
\nYou have decided to engage in some physical exercise. A friend suggests that you do this one hour twice a week and the best time for him is 7:00-8:00 am. Bearing in mind nothing else but your \n"feeling best" rhythm, how do you think you would perform?\n\n\n
\nAt what time in the evening do you feel tired and as a result, in need of sleep?\n\n
\nYou wish to be at your peak performance for a test, which you know is going to be mentally exhausting and lasting for two hours. You are entirely free to plan your day, and considering only your \nown "feeling best" rhythm, which ONE of the four testing times would you choose?\n\n\n
\nOne hears about "morning" and "evening" type people. Which ONE of these types do you consider yourself to be?\n\n
\nWhen would you prefer to rise (provided you have a full day's work - 8 hours) if you were totally free to arrange your time?\n\n
\nIf you always had to rise at 6:00 am, what do you think it would be like?\n\n
\nI am willing to work past my regular hours for more money.\n\n
\nHow long a time does it usually take before you "recover your senses" in the morning after rising from a night's sleep?\n\n
\nPlease indicate to what extent you are a morning or an evening active individual?\n\n
\nI have the thought that a major reason for my problems with substances is my own poor character.\n\n
\nI have the thought that I should be ashamed of myself.\n\n
\nI have the thought that I deserve the bad things that have happened to me.\n\n
\nI have the thought that I can't be trusted.\n\n
\nI feel inferior to people who have never had a problem with substances.\n\n
\nI feel out of place in the world because of my problems with substances.\n\n
\nI have the thought that I've permanently screwed up my life by using drugs.\n\n
\nI feel ashamed of myself.\n\n
\nThe kind of job I want is one that pays well for very little work.\n\n
\nPeople think I'm worthless if they know about my substance use history.\n\n
\nPeople around me will always suspect I have returned to using substances.\n\n
\nPeople without a substance use history could never really understand me.\n\n
\nA job interviewer wouldn't hire me if I mentioned my substance history in a job interview.\n\n
\nIf someone were to find out about my history of substance use, they would expect me to be weak-willed.\n\n
\nPeople would be scared of me if they knew about my substance abuse history.\n\n
\nPeople will think I have little talent or skill if they know about my substance history.\n\n
\nIf someone were to find out about my history of substance use, they would doubt my character.\n\n
\nPeople think the bad things that have happened to me are my fault.\n\n
\nI would choose to avoid someone who seemed interested in my friendship if I knew they had never used substances.\n\n
\nI would hate to live on welfare.\n\n
\nI do things that are good for me, even if I feel like I don't deserve it.\n\n
\nIf something is important to me, I keep doing it, even if I feel incompetent.\n\n
\nWhen I feel incompetent at something I want to do, I stop trying.\n\n
\nI'm willing to be in situations where I might feel different from others.\n\n
\nI am getting on with the business of living, no matter how guilty I feel.\n\n
\nI am open about my substance use history with most people.\n\n
\nI put a lot of effort into hiding my substance use history.\n\n
\nI avoid doing things where I would be blamed if it didn't work out.\n\n
\nI wouldn't try to fill roles that required a person of character.\n\n
\nShame gets in the way of how I want to live my life.\n\n
\nI am willing to do any work that is given to me.\n\n
\nI pursue important goals in life, even when I fear I might not follow through.\n\n
\nI can set a direction for my life even if I feel hopeless.\n\n
\nEven if I knew the employer didn't like to hire people in recovery, I would still apply for a job if it interested me.\n\n
\nI would lie to people in my life about my substance use if I were sure they would never find out.\n\n
\nI avoid situations where another person might have to depend on me.\n\n
\nI avoid situations that make me feel different.\n\n
\nI can't stand feeling like the bad things that happen to me are my fault.\n\n
\nI would willingly sacrifice important things in my life to feel like I fit in.\n\n
\nBlaming myself for my substance abuse history gets in the way of my success.\n\n
\nI can set a course in my life and stick to it, even when I feel like I'm a bad person.\n\n
\nI am not careful in most things that I do.\n\n
\nIf I didn't have a job, I would still look for one, even if it felt hopeless.\n\n
\nI would willingly sacrifice important life goals if that meant I could feel better about myself.\n\n
\nHave any of your blood relatives (i.e. children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?\n\n
\nHas a health professional ever told you that you have manic-depressive illness or bipolar disorder?\n\n
\nMy relationship is miserable vs. enjoyable:\n\n
\n(If present or abnormal) Did this behavior fluctuate during the interview (that is, tend to come-and-go or increase and decrease in severity)?\n\n
\n(If present or abnormal) Please describe this behavior.\n\n
\n(If present or abnormal) Did this behavior fluctuate during the interview (that is, tend |to come-and-go or increase and decrease in severity)?\n\n
\n(If present or abnormal) Please describe this behavior.\n\n
\n(If present or abnormal) Did this behavior fluctuate during the interview (that is, tend |to come-and-go or increase and decrease in severity)?\n\n
\nI'm a loser.\n\n
\nReceiving charity from other people does not bother me.\n\n
\n(If present or abnormal) Please describe this behavior.\n\n
\n(If present or abnormal) Did this behavior fluctuate during the interview (that is, tend |to come-and-go or increase and decrease in severity)?\n\n
\n(If present or abnormal) Please describe this behavior.\n\n
\nDid the patient have evidence of disturbance of the sleep-wake cycle, such as excessive daytime sleepiness with insomnia at night?\n\n
\n(If present or abnormal) Did this behavior fluctuate during the interview (that is, tend to come-and-go or increase and decrease in severity)?\n\n
\n(If present or abnormal) Please describe this behavior.\n\n
\n(If present or abnormal) Did this behavior fluctuate during the interview (that is, tend to come-and-go or increase and decrease in severity)?\n\n
\n(If present or abnormal) Please describe this behavior.\n\n
\nIf yes, please describe the disturbance:\n\n
\nDuring the past 3 months, how often have you failed to do what was normally expected of you because of your use of hallucinogens ( LSD, acid, PCP, Special K, ecstasy, etc.)?\n\n
\nI am willing to work at night.\n\n
\nRELIABILITY:\n\n
\nGLOBAL SEVERITY:\n\n
\nGLOBAL IMPROVEMENT:\n\n
\nTime (use 24 hour clock, midnight is 00:00):\n\n
\nPulse or heart rate (taken for one minute):\n\n
\nBlood pressure:\n\n
\nNAUSEA AND VOMITING - Ask, "Do you feel sick to your stomach? Have you vomited?" Observation:\n\n
\nTACTILE DISTURBANCES - Ask, "Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?" Observation:\n\n
\nTREMOR - Arms extended and fingers spread apart. Observation:\n\n
\nAUDITORY DISTURBANCES - Ask, "Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are \nnot there?" Observation:\n\n\n
\nI believe it is important to earn a living.\n\n
\nPAROXYSMAL SWEATS - Observation:\n\n
\nVISUAL DISTURBANCES - Ask, "Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know \nare not there?" Observation:\n\n\n
\nANXIETY - Ask, "Do you feel nervous?" Observation:\n\n
\nHEADACHE, FULLNESS IN HEAD - Ask, "Does your head feel different? Does it feel like there is a band around your head?" Do not rate for dizziness or lightheadedness. Otherwise, rate severity:\n\n
\nAGITATION - Observation:\n\n
\nORIENTATION AND CLOUDING OF SENSORIUM - Ask, "What day is this? Where are you? Who am I?"\n\n
\nSimulating a radio group with 10 columns:\n\n
\nSecond test of radio groups with 10 columns:\n\n
\nRadio group:\n\n
\nI do not worry if I am out of a job.\n\n
\nArgue with you about needing to be 100% ready to change your behavior.\n\n
\nShow you that she/he believes in your ability to change your behavior.\n\n
\nHelp you feel confident in your ability to change your behavior.\n\n
\nHelp you recognize the need to change your behavior.\n\n
\nPlease indicate the degree of happiness, all things considered, of your relationship.\n\n
\nName of Partner Completing this questionnaire:\n\n
\nI believe money is important.\n\n
\nI would rather beg than work for money.\n\n
\nI want to work to keep myself out of debt.\n\n
\nI do not believe in saving money.\n\n
\nI always do just what I want to do.\n\n
\nI never worry about getting food or clothing.\n\n
\nMy life is a mess.\n\n
\nWork should be avoided if possible.\n\n
\nThe government owes me a living.\n\n
\nI would rather follow the crowd than start anything by myself.\n\n
\nIf I am working at a job and finish early, I will look for something\nmore to do.\n\n
\nIf I take care of myself, I can avoid illness.\n\n
\nWhenever I get sick it is because of something\nI've done or not done.\n\n
\nGood health is largely a matter of good fortune.\n\n
\nNo matter what I do, if I am going to get sick I will get sick.\n\n
\nMost people do not realize the extent to which their illnesses\nare controlled by accidental happenings.\n\n
\nI can only do what my doctor tells me to do.\n\n
\nI'm a failure.\n\n
\nThere are so many strange diseases around that you can\nnever know how or when you might pick one up.\n\n
\nWhen I feel ill, I know it is because I have not been getting\nthe proper exercise or eating right.\n\n
\nPeople who never get sick are just plain lucky.\n\n
\nPeople's ill health results from their own carelessness.\n\n
\nI am directly responsible for my health.\n\n
\nWell thought of\n\n
\nMakes a good impression\n\n
\nAble to give orders\n\n
\nForceful\n\n
\nSelf-respecting\n\n
\nI'll never make it.\n\n
\nIndependent\n\n
\nAble to take care of self\n\n
\nCan be indifferent to others\n\n
\nCan be strict if necessary\n\n
\nFirm but just\n\n
\nCan be frank and honest\n\n
\nCritical of others\n\n
\nCan complain if necessary\n\n
\nOften gloomy\n\n
\nAble to doubt others\n\n
\nI feel so helpless.\n\n
\nFrequently disappointed\n\n
\nAble to criticize self\n\n
\nApologetic\n\n
\nCan be obedient\n\n
\nUsually gives in\n\n
\nGrateful\n\n
\nAdmires and imitates others\n\n
\nAppreciative\n\n
\nComputed Answer #1\n\n
\nComputed Answer #2\n\n
\nComputed Answer #3\n\n
\nComputed Answer #4\n\n
\nComputed Answer #5\n\n
\nComputed Answer #6\n\n
\nComputed Answer #7\n\n
\nComputed Answer #8\n\n
\nComputed Answer #9\n\n
\nVery anxious to be approved of\n\n
\nComputed Answer #10\n\n
\nComputed Answer #11\n\n
\nComputed Answer #12\n\n
\nComputed Answer #13\n\n
\nComputed Answer #14\n\n
\nComputed Answer #15\n\n
\nComputed Answer #16\n\n
\nComputed Answer #17\n\n
\nThoughts that you would be better off dead or of hurting yourself in some way\n\n
\nOver the past 2 weeks, have you felt down, depressed, or hopeless?\n\n
\nCooperative\n\n
\nOver the past 2 weeks, have you had thoughts of killing yourself?\n\n
\nIn your lifetime, have you ever attempted to kill yourself?\n\n
\nIf "Yes": When was the last time you attempted to kill yourself?\n\n
\nHave you ever experienced this kind of event?\n\n
\nHad nightmares about the event(s) or thought about the event(s) when you \ndid not want to?\n\n
\nTried hard not to think about the event(s) or went out of your way to \navoid situations that reminded you of the event(s)?\n\n
\nBeen constantly on guard, watchful, or easily startled?\n\n
\nFelt numb or detached from people, activities, or your surroundings?\n\n
\nFelt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?\n\n
\nLittle interest or pleasure in doing things\n\n
\nSomething has to change.\n\n
\nEager to get along with others\n\n
\nFeeling down, depressed, or hopeless\n\n
\nOver the past month, have you wished you were dead or wished you could go\nto sleep and not wake up?\n\n
\nOver the past month, have you had any actual thoughts of killing yourself?\n\n
\nOver the past month, have you been thinking about how you might do this? \n\n
\nOver the past month, have you had these thoughts and had some intention of\nacting on them?\n\n
\nOver the past month, have you started to work out or worked out the \ndetails of how to kill yourself?\n\n
\nIf yes, at any time in the past month did you intend to carry out this \nplan?\n\n
\nIn your lifetime, have you ever done anything, started to do anything, or \nprepared to do anything to end your life (for example, collected pills, obtained a gun, gave away valuables, went to the roof but didn't jump)?\n\n
\nIf YES, was this within the past 3 months?\n\n
\nFriendly\n\n
\nStanding for long periods such as 30 minutes?\n\n
\nTaking care of your household responsibilities?\n\n
\nLearning a new task, for example, learning how to get to a new place?\n\n
\nHow much of a problem did you have joining in community activities (for \nexample, festivities, religious or other activities) in the same way as \nanyone else can?\n\n
\nHow much have you been emotionally affected by your health problems?\n\n
\nConcentrating on doing something for ten minutes?\n\n
\nWalking a long distance such as a kilometer (or equivalent)?\n\n
\nWashing your whole body?\n\n
\nGetting dressed?\n\n
\nDealing with people you do not know?\n\n
\nAffectionate and understanding\n\n
\nMaintaining a friendship?\n\n
\nYour day-to-day work?\n\n
\nHave you ever experienced this kind of event?\n\n
\nHad nightmares about the event(s) or thought about the event(s) when you did not want to?\n\n
\nTried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)?\n\n
\nBeen constantly on guard, watchful, or easily startled?\n\n
\nFelt numb or detached from people, activities, or your surroundings?\n\n
\n \nFelt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?\n\n
\nOver the last 2 weeks, how often have you been bothered by thoughts that \nyou would be better off dead or of hurting yourself in some way?\n\n
\nConsiderate\n\n
\nSomatic Concern - Degree of concern over present bodily health is perceived as problem by the patient, whether the complaints have a realistic basis or not. Do not rate mere reporting of somatic symptoms. Rate only concerns for (or worrying abou\nt) physical problems (real or imagined).\n\n
\nAnxiety - Worry, fear, or over concern for present or future. Rate solely\non the basis of verbal report of the patient's own subjective\nexperiences. Do not infer anxiety from physical signs or from neurotic\ndefense mechanisms. Do not rate if restricted to somatic concern.\n\n
\nEmotional withdrawal - Deficiency in relating to the interviewer and to the interview situation. Overt manifestations of this deficiency include poor/absence of eye contact, failure to orient oneself physically toward the interviewer, and a gene\nral lack of involvement or engagement in the interview. Distinguish from BLUNTED AFFECT, in which deficits in facial expression, body gesture, and voice pattern are scored. [DO NOT SELECT 'Severe' or 'Very Severe' IF EXPLAINED BY DISORIENTATION]\n.\n\n
\nConceptual Disorganization - Degree of speech incomprehensibility.\nInclude any type of formal thought disorder (e.g., loose associations,\nincoherence, flight of ideas, neologisms). DO NOT include mere\ncircumstantiality or pressured speech, even if marked. DO NOT rate on the\npatient's subjective impressions (e.g., "My thoughts are racing", "I\ncan't hold a thought", "My thinking gets all mixed up"). Rate ONLY on the\nbasis of observations made during the interview.\n\n
\nGuilt Feelings - Overconcern or remorse for past behavior. Rate on\npatient's subjective experiences of guilt as evidenced by verbal report.\nDo not infer guilt feelings from depression, anxiety, or neurotic\ndefenses.\n\n
\nTension - Rate motor restlessness (agitation) observed during the\ninterview. DO NOT rate on the basis of subjective experiences reported by\nthe patient. Disregard suspected pathogenesis (e.g., tardive dyskinesia).\n\n
\nMannerisms And Posturing - Unusual and unnatural motor behavior. Rate\nonly abnormality of movements; do not rate simple heightened motor\nactivity here. Consider frequency, duration, and degree of bizarreness.\nDisregard suspected pathogenesis.\n\n
\nGrandiosity - Inflated self-esteem (self-confidence), or inflated\nappraisal of one's talents, powers, abilities, accomplishments,\nknowledge, importance, or identity. Do not score mere grandiose quality\nof claims (e.g., "I'm the worst sinner in the world," "The entire country\nis trying to kill me") unless the guilt/persecution is related to some\nspecial exaggerated attribute of the individual. Also, the patient must\nclaim exaggerated attributes: e.g., If patient denies talents, powers,\netc., even if he/she states that others indicate that he/she has these\nattributes, this item should not be scored.\n\n
\nDepressive Mood - Subjective report of feeling depressed, blue "down in\nthe dumps," etc. Rate only the degree of reported depression. Do not rate\non the basis of inferences concerning depression based upon general\nretardation and somatic complaints.\n\n
\nEncourages others\n\n
\nHostility - Animosity, contempt, belligerence, disdain for other people outside the interview situation. Rate solely on the basis of the verbal report of feelings and actions of the patient toward others. Do not infer \nhostility from neurotic defenses, anxiety, or somatic complaints.\n\n
\nSuspiciousness - Belief (delusional or otherwise) that others have now,\nor have had in the past, malicious or discriminatory intent toward the\npatient. On the basis of verbal report, rate only those suspicions which\nare currently held whether they concern past or present circumstance.\n\n
\nHallucinatory Behavior - Perceptions (in any sense modality) in absence\nof identifiable external stimulus. Rate only experiences that have\noccurred during the last week. DO NOT rate "voices in my head" or\n"visions in my mind" unless the patient can differentiate between these\nexperiences and his or her thoughts.\n\n
\nMotor Retardation - Reduction in energy level evidenced in slowed\nmovements. Rate on the basis of observed behavior of the patient only. Do\nnot rate on the basis of the patient's subjective impression of his or\nher own energy level.\n\n
\nUncooperativeness - Evidence of resistance, unfriendliness, resentment,\nand lack of readiness to cooperate with the interviewer. Rate solely on\nthe basis of the patient's attitude and responses to the interviewer and\nthe interview situation. Do not rate on the basis of reported resentment\nor uncooperativeness outside the interview situation.\n\n
\nUnusual Thought Content - Severity of delusions of any type -- consider\nconviction and effect on actions. Assume full conviction if patient has\nacted on his or her beliefs.\n\n
\nBlunted Affect - Diminished affective responsivity, as characterized by\ndeficits in facial expression, body gesture, and voice pattern.\nDistinguish from EMOTIONAL WITHDRAWAL, in which the focus is on\ninterpersonal impairment rather than affect. Consider degree and\nconsistency of impairment.\n\n
\nExcitement - Heightened emotional tone, including irritability and\nexpansiveness (hypomanic affect). Do not infer affect from statements of\ngrandiose delusions.\n\n
\nDisorientation - Confusion or lack of proper association for person, place or time.\n\n
\nDid the patient screen positive on both PSS items - active ideation with a past attempt?\n|Source: PSS screener completed by primary nurse, documented on chart.\n\n
\nHelpful\n\n
\nHas the individual begun a suicide plan?\n \n|Source: Use patient self-report, collateral information.\n|Suggested wording: Have you been thinking about how you might kill yourself?\n\n
\nHas the individual recently had intent to act on his/her ideation?\n|Source: Use Patient self-report, collateral information.\n|Suggested wording: Have you had some intention of acting on your thoughts?\n\n
\nHas the patient ever had a psychiatric hospitalization?\n|Source: Use patient self-report, collateral information, medical records review.\n|Suggested wording: Have you ever been hospitalized for a mental health or substance use problem?\n\n
\nDoes the patient have a pattern of excessive substance use?\n|Source: Use patient self-report, collateral information, medical records review.\n \n|Suggested wording: Has drinking or drug abuse ever been a problem for\nyou? Or administer CAGE or other standardized substance use screener.\n\n
\nIs the patient irritable, agitated, or aggressive?\n|Source: Use current observations, collateral information, medical records review.\n\n
\nRepeated, disturbing, and unwanted memories of the stressful experience?\n\n
\nRepeated, disturbing dreams of the stressful experience?\n\n
\nSuddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?\n\n
\nFeeling very upset when something reminded you of the stressful experience?\n\n
\nHaving strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?\n\n
\nBig-hearted and unselfish\n\n
\nAvoiding memories, thoughts, or feelings related to the stressful experience?\n\n
\nAvoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?\n\n
\nTrouble remembering important parts of the stressful experience?\n\n
\nHaving 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)?\n\n
\nBlaming yourself or someone else for the stressful experience or what happened after it?\n\n
\nHaving strong negative feelings such as fear, horror, anger, guilt, or shame?\n\n
\nLoss of interest in activities that you used to enjoy?\n\n
\nFeeling distant or cut off from other people?\n\n
\nTrouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?\n\n
\nIrritable behavior, angry outbursts, or acting aggressively?\n\n
\nOften admired\n\n
\nTaking too many risks or doing things that could cause you harm?\n\n
\nBeing "super alert" or watchful or on guard?\n\n
\nFeeling jumpy or easily startled?\n\n
\nHaving difficulty concentrating?\n\n
\nTrouble falling or staying asleep?\n\n
\nHow soon after you wake up do you smoke/use your first cigarette?\n\n
\nHow many cigarettes do you smoke in a day?\n\n
\nI've been feeling optimistic about the future.\n\n
\nI've been feeling useful.\n\n
\nI've been feeling relaxed.\n\n
\nRespected by others\n\n
\nI've been feeling interested in other people.\n\n
\nI've had energy to spare.\n\n
\nI've been dealing with problems well.\n\n
\nI've been thinking clearly.\n\n
\nI've been feeling good about myself.\n\n
\nI've been feeling close to other people.\n\n
\nI've been feeling confident.\n\n
\nI've been able to make up my own mind about things.\n\n
\nI've been feeling loved.\n\n
\nI've been interested in new things.\n\n
\nGood leader\n\n
\nI've been feeling cheerful.\n\n
\nI work hard toward my mental health recovery.\n\n
\nEven though there are hard days, things are improving for me.\n\n
\nI ask for help when I am not feeling well.\n\n
\nI take risks to move forward with my recovery.\n\n
\nI believe in myself.\n\n
\nI have control over my mental health problems.\n\n
\nI am in control of my life.\n\n
\nI socialize and make friends.\n\n
\nEvery day is a new opportunity for learning.\n\n
\nThere must be something wrong with me.\n\n
\nLikes responsibility\n\n
\nI still grow and change in positive ways despite my mental health problems.\n\n
\nEven though I may still have problems, I value myself as a person of worth.\n\n
\nI understand myself and have a good sense of who I am.\n\n
\nI eat nutritious meals every day.\n\n
\nI go out and participate in enjoyable activities every week.\n\n
\nI make the effort to get to know other people.\n\n
\nI am comfortable with my use of prescribed medications.\n\n
\nI feel good about myself.\n\n
\nThe way I think about things helps me to achieve my goals.\n\n
\nMy life is pretty normal.\n\n
\nSelf-confident\n\n
\nI feel at peace with myself.\n\n
\nI maintain a positive attitude for weeks at a time.\n\n
\nMy quality of life will get better in the future.\n\n
\nEvery day that I get up, I do something productive.\n\n
\nI am making progress towards my goals.\n\n
\nWhen I am feeling low, my religious faith or spirituality helps me feel better.\n\n
\nMy religious faith or spirituality supports my recovery.\n\n
\nI advocate for the rights of myself and others with mental health problems.\n\n
\nI engage in work or other activities that enrich myself and the world around me.\n\n
\nI cope effectively with stigma associated with having a mental health problem.\n\n
\nSelf-reliant and assertive\n\n
\nI have enough money to spend on extra things or activities that enrich my life.\n\n
\nComputed Answer #18\n\n
\nComputed Answer #19\n\n
\nComputed Answer #20\n\n
\nComputed Answer #21\n\n
\nProblems with judgement (e.g., problems making decisions, bad financial \ndecisions, problems with thinking)\n\n
\nLess interest in hobbies/activities\n\n
\nRepeats the same things over and over (questions, stories, or statements)\n\n
\nTrouble learning how to use a tool, appliance, or gadget (e.g., VCR, computer, microwave, remote control)\n\n
\nBusiness-like\n\n
\nForgets correct month or year\n\n
\nTrouble handling complicated financial affairs (e.g., balancing checkbook, income taxes, paying bills)\n\n
\nTrouble remembering appointments\n\n
\nDaily problems with thinking and/or memory\n\n
\nI have been able to laugh and see the funny side of things\n\n
\nI have looked forward with enjoyment to things\n\n
\nI have blamed myself unnecessarily when things went wrong\n\n
\nI have been anxious or worried for no good reason\n\n
\nI have felt scared or panicky for no very good reason\n\n
\nThings have been getting on top of me\n\n
\nLikes to compete with others\n\n
\nI have been so unhappy that I have had difficulty sleeping\n\n
\nI have felt sad or miserable\n\n
\nI have been so unhappy that I have been crying\n\n
\nThe thought of harming myself has occurred to me\n\n
\nDid you ever go on combat patrols or have other dangerous duty?\n\n
\nWere you ever under enemy fire?\n\n
\nWere you ever surrounded by the enemy?\n\n
\nWhat percentage of the soldiers in your unit were killed (KIA), wounded \nor missing in action (MIA)?\n\n
\nHow often did you fire rounds at the enemy?\n\n
\nHow often did you see someone hit by incoming or outgoing rounds?\n\n
\nHard-boiled when necessary\n\n
\nHow often were you in danger of being injured or killed (i.e., being pinned down, overrun, ambushed, near miss, etc.)?\n\n
\nHow soon after you wake up do you smoke/use your first cigarette/chew?\n\n
\nDo you smoke/chew more frequently in the hours after waking than during the rest of the day?\n\n
\nDo you find it difficult not to smoke/chew?\n\n
\nWhich cigarette/chew would be the hardest to give up?\n\n
\nHow many cigarettes do you smoke in a day?\n\n
\nDo you smoke when you're so sick that you're home in bed?\n\n
\nThink you had special powers?\n\n
\nHear voices or see things?\n\n
\nThink people were watching you?\n\n
\nStern but fair\n\n
\nThink people were against you?\n\n
\nIn general, how much does your pain problem interfere with your day to day activities?\n\n
\nAre you retired from work for reasons other than your pain problem?\n\n
\nSince the time you developed a pain problem, how much has your pain \nchanged your ability to work?\n\n
\nHow much has your pain changed the amount of satisfaction or enjoyment you get from participating in social and recreational activities?\n\n
\nHow much has your pain changed your ability to participate in recreational and other social activities?\n\n
\nHow much has your pain changed the amount of satisfaction you get from family-related activities?\n\n
\nHow much has your pain changed your marriage and other family relationships?\n\n
\nAre you currently working?\n\n
\nHow much has your pain changed the amount of satisfaction or enjoyment you get from work?\n\n
\nIrritable\n\n
\nHow much has your pain changed your ability to do household chores?\n\n
\nHow much has your pain changed your friendships with people other than your family?\n\n
\nI feel good about this job.\n\n
\nThis job is worthwhile.\n\n
\nThe working conditions are good.\n\n
\nI want to quit this job.\n\n
\nThis job is boring.\n\n
\nI am happy about the amount of money that this job pays.\n\n
\nThe vacation time and other benefits are okay.\n\n
\nI need more money than this job pays.\n\n
\nStraightforward and direct\n\n
\nThis job does not provide the medical coverage I need.\n\n
\nI have a fairly good chance for promotion in this job.\n\n
\nThis is a dead-end job.\n\n
\nI feel that there is a good chance of my losing this job in the future.\n\n
\nMy supervisor is fair.\n\n
\nMy supervisor is hard to please.\n\n
\nMy supervisor praises me when I do my job well.\n\n
\nMy supervisor is difficult to get along with.\n\n
\nMy supervisor recognizes my efforts.\n\n
\nMy co-workers are easy to get along with.\n\n
\nResents being bossed\n\n
\nMy co-workers are lazy.\n\n
\nMy co-workers are unpleasant.\n\n
\nMy co-workers don't like me.\n\n
\nMy co-workers help me to like this job more.\n\n
\nI have a co-worker I can rely on.\n\n
\nI have a co-worker I consider a friend.\n\n
\nI look forward to coming to work.\n\n
\nI often feel tense on the job.\n\n
\nI don't know what's expected of me on this job.\n\n
\nI feel physically worn out at the end of the day.\n\n
\nGlobal Judgments\n \nSeverity of abnormal movements.\n \n\n
\nMy future is bleak.\n\n
\nSkeptical\n\n
\nWorking makes me feel like I'm needed.\n\n
\nMy job keeps me busy.\n\n
\nI get to do a lot of different things on my job.\n\n
\nI am satisfied with my schedule.\n\n
\nOver the past 2 weeks, how often have you had thoughts that you would be better off dead or of hurting yourself in some way?\n\n
\nOver the past month, have you wished you were dead or wished you could go to sleep and not wake up?\n\n
\nOver the past month, have you had any actual thoughts of killing yourself?\n\n
\nOver the past month, have you been thinking about how you might do this?\n\n
\nOver the past month, have you had these thoughts and had some intention of acting on them? \n\n
\nOver the past month, have you started to work out or worked out the details of how to kill yourself?\n\n
\nHard to impress\n\n
\nIf yes, at any time in the past month did you intend to carry out this plan?\n\n
\nIn your lifetime, have you ever done anything, started to do anything, or prepared to do anything to end your life (for example, collected pills, obtained a gun, gave away valuables, went to the roof but didn't jump)?\n\n
\nIf YES, was this within the past 3 months?\n\n
\nLately, my strength seems to be draining out of me, even in the morning.\n\n
\nI always make sure that my work is well planned and organized.\n\n
\nI enjoy doing so many different things that I can't make up my mind what \nto do first.\n\n
\nI'm concerned that people I depend on will leave me.\n\n
\nAlthough I'm afraid to make friendships, I wish I had more than I do.\n\n
\nTouchy and easily hurt\n\n
\nWhat few feelings I seem to have, I rarely show to the outside world.\n\n
\nI have a hard time keeping my balance when walking.\n\n
\nI'm always looking for opportunities that are exciting and new for me.\n\n
\nSometimes I can be pretty rough and mean in my relations with my family.\n\n
\nI like being the center of attention.\n\n
\nAs a teenager, I got into lots of trouble because of bad school behavior.\n\n
\nI'm afraid to get really close to another person because it may end up with my being ridiculed or shamed.\n\n
\nI can tell that people are talking about me when I pass by them.\n\n
\nI began to feel like a failure some years ago.\n\n
\nWhen I have a choice, I prefer to do things alone.\n\n
\nEasily embarrassed\n\n
\nLately, I have begun to feel like smashing things.\n\n
\nThings that are going well today won't last very long.\n\n
\nI sometimes feel crazy-like or unreal when things start to go badly in my life.\n\n
\nI do what I want without worrying about its effect on others.\n\n
\nI approach my daily activities with lots of energy and persistence.\n\n
\nI never forgive an insult or forget an embarrassment someone has caused me.\n\n
\nI feel terribly depressed and sad much of the time now. \n\n
\nI tend to always blame myself when things go wrong.\n\n
\nA long time ago, I decided it's best to have little to do with people.\n\n
\nI have an alcohol problem that has made difficulties for me and my family.\n\n
\nLacks self-confidence\n\n
\nI'm a very socially inhibited and shy person.\n\n
\nThere are many times when, for no reason, I feel very cheerful and full of excitement.\n\n
\nIn recent weeks, I feel worn out for no special reason.\n\n
\nMy time is more valuable than others'.\n\n
\nI am always looking to make new friends and meet new people.\n\n
\nI've become very jumpy in the last few weeks.\n\n
\nI just haven't had the luck in life that others have had.\n\n
\nIdeas keep turning over and over in my mind and they won't go away.\n\n
\nI've become quite discouraged and sad about life in the past year or two.\n\n
\nI try to make everything I do as perfect as possible.\n\n
\nEasily led\n\n
\nMy habit of abusing drugs has caused me to miss work in the past.\n\n
\nMy moods seem to change a great deal from one day to the next.\n\n
\nI use my charm to get my way.\n\n
\nI often think that I don't deserve the good things that happen to me.\n\n
\nI have cut or hurt myself in the past on purpose.\n\n
\nI can't seem to sleep, and wake just as tired as when I went to bed.\n\n
\nI often let others make important decisions for me.\n\n
\nNothing much that happens seems to make me either sad or happy.\n\n
\nI keep having strange thoughts that I wish I could get rid of.\n\n
\nI have a great deal of trouble trying to control an impulse to drink in excess.\n\n
\nModest\n\n
\nI make friends much more easily than most people I know.\n\n
\nI'm ashamed of some of the abuses I suffered when I was young.\n\n
\nI think highly of rules because they are a good guide to follow.\n\n
\nI was on the front cover of several magazines last year.\n\n
\nI often get angry with people who do things slowly.\n\n
\nI spend my life worrying over one thing or another.\n\n
\nI always wonder what the real reason is when someone is acting especially nice to me.\n\n
\nI'm animated and inspired by my daily activities.\n\n
\nI have many ideas that are ahead of the times.\n\n
\nI can no longer concentrate on anything since I experienced serious concussions.\n\n
\nOften helped by others\n\n
\nPeople have said in the past that I became too interested and too excited about too many things.\n\n
\nI have completely lost my appetite and have trouble sleeping most nights. \n\n
\nEver since I was a child, I have been losing touch with the real world.\n\n
\nI can't experience much pleasure because I don't feel I deserve it.\n\n
\nI prefer being told what to do rather than having to decide for myself.\n\n
\nMy use of so-called "illegal" drugs has led to family arguments.\n\n
\nThe memory of a very upsetting experience in my past keeps coming back to haunt my thoughts.\n\n
\nI'm considered by most to be a prudent and careful person.\n\n
\nI seem to have lost interest in most things that I used to find pleasurable, such as sex.\n\n
\nI've gotten into trouble with the law a couple of times.\n\n
\nVery respectful to authority\n\n
\nI have had to be really rough with some people to keep them in line.\n\n
\nI am very confident.\n\n
\nPeople are trying to make me believe that I'm crazy.\n\n
\nI go on eating binges a couple of times a week.\n\n
\nI frequently feel there's nothing inside me, like I'm empty and hollow.\n\n
\nI've always had a hard time stopping myself from feeling blue and unhappy.\n\n
\nWhen I'm alone and away from home, I often begin to feel tense and panicky.\n\n
\nPeople tell me that I'm a very proper and moral person.\n\n
\nI have difficulty controlling my anger.\n\n
\nI'm a very optimistic person.\n\n
\nAccepts advice readily\n\n
\nYears later, I still have nightmares about an event that was a real threat to my life.\n\n
\nI seem to need a lot of advice to get things done.\n\n
\nI have given serious thought recently to doing away with myself.\n\n
\nSneaky people try to get credit for things I've done or thought of.\n\n
\nLately, I've gone all to pieces.\n\n
\nTaking so-called "illegal" drugs may be unwise, but in the past I've found I needed them.\n\n
\nI'm a very erratic person, changing my mind and feelings all the time.\n\n
\nI'm very good at making up excuses when I get into trouble.\n\n
\nI never sit on the sidelines when I'm at a party.\n\n
\nI seem to make a mess of good opportunities that come my way.\n\n
\nIt's just not worth it.\n\n
\nTrusting and eager to please\n\n
\nI sometimes force myself to vomit after eating.\n\n
\nI'm a special person, so I don't care what others think.\n\n
\nI watch my family closely so I'll know who can and who can't be trusted.\n\n
\nThere are certain thoughts that keep coming back again and again in my mind.\n\n
\nFew things in life give me pleasure.\n\n
\nI feel shaky and have difficulty falling asleep because painful memories of a past event keep running through my mind.\n\n
\nI often get lost in my thoughts and forget what's going on around me.\n\n
\nI've never been able to shake the feeling that I'm worthless to others.\n\n
\nI have a drinking problem that I've tried unsuccessfully to end.\n\n
\nSomeone has been trying to control my mind.\n\n
\nAlways pleasant and agreeable\n\n
\nMost successful people have either been lucky or dishonest.\n\n
\nI often make people angry by bossing them.\n\n
\nI have not seen a car in the last 10 years. \n\n
\nI always feel self-conscious and tense at social gatherings.\n\n
\nI seem to create situations in which I get hurt or feel rejected.\n\n
\nI feel deeply depressed for no reason I can figure out.\n\n
\nPeople say I'm a thin person, but I feel that my thighs and backside are much too big.\n\n
\nI often enjoy starting an argument or a fight.\n\n
\nI take great care to keep my life private so no one can take advantage of me.\n\n
\nMy drug habits have often gotten me into a good deal of trouble in the past.\n\n
\nWants everyone to like him\n\n
\nI often get blamed for things I am not responsible for.\n\n
\nLooking ahead as each day begins makes me feel terribly depressed.\n\n
\nPeople sometimes get annoyed with me because they say I talk too much or too fast for them.\n\n
\nI could never handle the world on my own.\n\n
\nMy brain just hasn't functioned properly since injuries it received in recent years.\n\n
\nI feel lonely and empty most of the time.\n\n
\nPeople make fun of me behind my back.\n\n
\nLately, I've been sweating a great deal and feel very tense. \n\n
\nIn recent weeks, my mood has become increasingly sad.\n\n
\nI blow up angrily very fast at people who bother me.\n\n
\nSociable and neighborly\n\n
\nThere are times when I couldn't get through the day without some street drugs.\n\n
\nI like to flirt a lot.\n\n
\nI don't have the energy to concentrate on my everyday responsibilities anymore.\n\n
\nMy emotions don't seem to be as strong as other people's.\n\n
\nI feel weak and tired much of the time.\n\n
\nStrange ideas from outside keep turning over in my mind and they won't go away.\n\n
\nOthers get breaks that I don't.\n\n
\nI repeat certain behaviors again and again, sometimes to reduce my anxiety and sometimes to stop something bad from happening.\n\n
\nI have taken prescription medication that was not meant for me.\n\n
\nMy current life is still upset by flashbacks of something terrible that happened to me.\n\n
\nWarm\n\n
\nI often ruin the good things that happen to me.\n\n
\nEvil voices are trying to take over my mind.\n\n
\nI feel very guilty when I lose my temper. \n\n
\nMy enthusiasm for the work I do never really diminishes.\n\n
\nI guess I'm no different from my parents in becoming somewhat of an alcoholic.\n\n
\nLately, I have had to think things over and over again for no good reason.\n\n
\nI encourage people to admire the things I say or do.\n\n
\nI give up doing things when I have to do them alone.\n\n
\nI have tried to commit suicide.\n\n
\nI am a fearful and inhibited person.\n\n
\nKind and reassuring\n\n
\nPeople who are supposed to be my friends would like to do me harm.\n\n
\nI often let my angry feelings out and then feel very guilty about it.\n\n
\nI very often hear things so well that it bothers me.\n\n
\nOther than my family, I have very few close relationships.\n\n
\nDisorganization makes me feel very uncomfortable. \n\n
\nI often criticize people strongly if they annoy me.\n\n
\nI have many talents that others wish they had.\n\n
\nThere are terrible events from my past that come back repeatedly to haunt my thoughts and dreams.\n\n
\nI know I've spent more money than I should buying illegal drugs.\n\n
\nBefore I know it, I often start shouting angrily at friends and family.\n\n
\nTender and soft-hearted\n\n
\nIt bothers me that my body gets worn out very quickly.\n\n
\nIt's all right to get around the law if you're not likely to get caught.\n\n
\nI believe I'm being plotted against.\n\n
\nI'm a loner and I don't mind it.\n\n
\nI still feel terrified when I think of a traumatic experience I had years ago.\n\n
\nFor some time now, I've been feeling very guilty because I can't do things right anymore.\n\n
\nPunishment never stopped me from doing what I wanted.\n\n
\nI rarely believe what people tell me.\n\n
\nI'm a very sociable and outgoing person.\n\n
\nI've become enthusiastic about almost anything I do.\n\n
\nEnjoys taking care of others\n\n
\nI am confused about who I am.\n\n
\nI hate to think about some of the ways I was abused as a child.\n\n
\nI would never break the law, even if I could get away with it.\n\n
\nThere are members of my family who say I'm selfish and think only of myself.\n\n
\nI flew across the Atlantic 30 times last year.\n\n
\nDrinking alcohol helps when I'm feeling down.\n\n
\nI would much rather follow someone than be the leader.\n\n
\nIdeas often race through my mind much faster than I can speak them.\n\n
\nI often get so upset that I want to hurt myself seriously. \n\n
\nSome people say I'm a strange or odd person.\n\n
\nGives freely of self\n\n
\nSometimes I find comfort in my misery.\n\n
\nI often find that I've been treated unfairly.\n\n
\nI quickly show my anger at people who disagree with me.\n\n
\nI feel guilty much of the time and often don't know why.\n\n
\nI've been feeling sad and blue and can't seem to snap out of it.\n\n
\nI know how to charm people.\n\n
\nI have always had to watch out for people who are trying to cheat me.\n\n
\nI'm always willing to go along with what others would like to do.\n\n
\nI approach all of life's challenges with a bold and vigorous attitude.\n\n
\nI never feel like I have anything worthwhile to contribute to a conversation.\n\n
\nAlways giving advice\n\n
\nIf a medication is not helping me, I may take it more frequently or increase the dose.\n\n
\nI've had many periods in my life when I was so cheerful and used up so much energy that I fell into a low mood.\n\n
\nI often feel very unhappy with who I am.\n\n
\nI don't like to change my routine.\n\n
\nI don't need to have close friendships like other people do.\n\n
\nPhysically hurting myself has sometimes brought me comfort.\n\n
\nMany people have been spying into my private life for years.\n\n
\nI'm pretty good at deceiving people when I want to.\n\n
\nEven in good times, I've always been afraid things would soon go bad.\n\n
\nI am very good at inspiring and energizing others.\n\n
\nI can't finish anything.\n\n
\nActs important\n\n
\nI'm willing to starve myself to be even thinner than I am.\n\n
\nI am often irritable and short-tempered.\n\n
\nI always try to finish my work before taking time out for leisure activities.\n\n
\nPeople would have to be exceptional themselves to understand my abilities.\n\n
\nI really don't understand human feelings like other people do.\n\n
\nToo many rules get in the way of doing what I want.\n\n
\nI sometimes feel I deserve to be unhappy.\n\n
\nI've been downhearted and sad much of my life.\n\n
\nI tend to go along with others' opinions.\n\n
\nI avoid most social situations because I expect people will reject me.\n\n
\nBossy\n\n
\nYour physical health?\n\n
\nYour mood?\n\n
\nYour work?\n\n
\nYour household activities?\n\n
\nYour social relationships?\n\n
\nYour family relationships?\n\n
\nYour leisure time activities?\n\n
\nYour ability to function in daily life?\n\n
\nYour sexual drive, interest and/or performance?\n\n
\nDominating\n\n
\nYour economic status?\n\n
\nYour living/housing situation?\n\n
\nYour ability to get around physically without feeling dizzy or unsteady \nor falling?\n\n
\nYour vision in terms of ability to do work or hobbies?\n\n
\nYour overall sense of well-being?\n\n
\nYour medication?\n\n
\nHow would you rate your overall life satisfaction and contentment during \nthe past week?\n\n
\nHead (headache pain)?\n\n
\nJaw or face?\n\n
\nNeck or shoulders?\n\n
\nBoastful\n\n
\nArms or hands?\n\n
\nChest?\n\n
\nAbdomen or stomach?\n\n
\nMiddle back?\n\n
\nLower back?\n\n
\nGenital area?\n\n
\nLegs or feet?\n\n
\nTaking into account all parts of your body that hurt, what was your overall highest level of pain during the past month?\n\n
\nTaking into account all parts of your body that hurt, what was your overall lowest level of pain during the past month?\n\n
\nTaking into account all parts of your body that hurt, what is your overall level of pain right now?\n\n
\nProud and self-satisfied\n\n
\nTaking into account all parts of your body that hurt, what level of pain could you tolerate and still work and get on with your life?\n\n
\nFeeling exhausted but being unable to sleep?\n\n
\nIrritability?\n\n
\nShakiness or jitters?\n\n
\nBeing unable to relax?\n\n
\nFeeling that nothing seems real?\n\n
\nLump in throat/difficulty swallowing?\n\n
\nPounding or racing heart when not exerting yourself?\n\n
\nHearing voices that other people don't hear?\n\n
\nFeeling bloated or gassy?\n\n
\nThinks only of himself\n\n
\nLack of interest in sex?\n\n
\nDifficulty concentrating?\n\n
\nI am satisfied with the medical care I am receiving.\n\n
\nI am barely able to keep up with my work.\n\n
\nI worry about becoming dependent on prescription medication.\n\n
\nI walk and move very carefully so I won't cause myself pain.\n\n
\nThings have been terrible at home lately.\n\n
\nI've had no problems with sleeping.\n\n
\nI am not disabled.\n\n
\nI have never abused alcohol or drugs.\n\n
\nShrewd and calculating\n\n
\nI can't work.\n\n
\nSomebody owes me for all of my pain and suffering.\n\n
\nPain would not stop me from doing my favorite things.\n\n
\nI am very angry with one or more of my doctors.\n\n
\nMy physical problems really don't bother me that much.\n\n
\nI protect my health by staying at home.\n\n
\nMy pain never changes.\n\n
\nI feel well enough to work.\n\n
\nI'm afraid that my poor health will ruin my most important relationships.\n\n
\nThere are many jobs that I am capable of doing.\n\n
\nImpatient with others' mistakes\n\n
\nMy life is full and satisfying.\n\n
\nI am afraid of pushing myself too hard.\n\n
\nWith my kind of problems, there's little hope of getting better.\n\n
\nThis has been one of the worst times of my life.\n\n
\nI get so restless at times that I can't stand still.\n\n
\nMy life used to be much better than it is now.\n\n
\nI am allergic to the glass found in jars.\n\n
\nI am afraid that my physical problems might kill me.\n\n
\nLately, I have been thinking about suicide a lot.\n\n
\nI am content with my life.\n\n
\nSelf-seeking (seeks personal gain -- selfish)\n\n
\nI fear being struck down by an attack of some illness.\n\n
\nMy life seems like one defeat after another.\n\n
\nMy health problems really aren't that serious.\n\n
\nWhen I think about my physical problems, I get depressed.\n\n
\nMy life shouldn't be this hard.\n\n
\nI often get depressed; it's like I fall in a hole and can't get out.\n\n
\nI have many severe problems that come and go.\n\n
\nThere are many things I won't do for fear of hurting myself.\n\n
\nRecently my life has been a nightmare.\n\n
\nI'm often afraid that something bad will happen to me.\n\n
\nOutspoken\n\n
\nPhysical Functioning: Are you able to do chores such as vacuuming or yard\nwork?\n\n
\nPhysical Functioning: Are you able to go up and down stairs at a normal\npace?\n\n
\nPhysical Functioning: Are you able to go for a walk of at least 15\nminutes?\n\n
\nPhysical Functioning: Are you able to run errands and shop?\n\n
\nAnxiety: IN THE PAST 7 DAYS I felt fearful.\n\n
\nAnxiety: IN THE PAST 7 DAYS I found it hard to focus on anything other\nthan my anxiety.\n\n
\nAnxiety: IN THE PAST 7 DAYS my worries overwhelmed me.\n\n
\nAnxiety: IN THE PAST 7 DAYS I felt uneasy.\n\n
\nDepression: IN THE PAST 7 DAYS I felt worthless.\n\n
\nDepression: IN THE PAST 7 DAYS I felt helpless.\n\n
\nHow often did you have a drink containing alcohol in the past year? Consider a drink to be a 12 ounce can or bottle of regular beer,\n 8 ounces of malt liquor, a 5 ounce glass of table wine, or a 1.5 ounce shot of liquor (like scotch, gin, or vodka).\n\n
\nOften unfriendly\n\n
\nDepression: IN THE PAST 7 DAYS I felt depressed.\n\n
\nDepression: IN THE PAST 7 DAYS I felt hopeless.\n\n
\nFatigue: DURING THE PAST 7 DAYS I feel fatigued.\n\n
\nFatigue: DURING THE PAST 7 DAYS I have trouble STARTING things because I am tired.\n\n
\nFatigue: IN THE PAST 7 DAYS - How run down did you feel on average?\n\n
\nFatigue: IN THE PAST 7 DAYS - How fatigued were you on average?\n\n
\nSleep Disturbance: IN THE PAST 7 DAYS my sleep quality was,\n\n
\nSleep Disturbance: IN THE PAST 7 DAYS my sleep was refreshing,\n\n
\nSleep Disturbance: IN THE PAST 7 DAYS I had a problem with sleep,\n\n
\nSleep Disturbance: IN THE PAST 7 DAYS I had difficulty falling asleep,\n\n
\nBitter\n\n
\nSatisfaction with Social Role: IN THE PAST 7 DAYS I am satisfied with how\nmuch work I can do (include work at home).\n\n
\nSatisfaction with Social Role: IN THE PAST 7 DAYS I am satisfied with my\nability to work (include work at home).\n\n
\nSatisfaction with Social Role: IN THE PAST 7 DAYS I am satisfied with my\nability to do regular personal and household responsibilities.\n\n
\nSatisfaction with Social Role: IN THE PAST 7 DAYS I am satisfied with my\nability to perform my daily routines.\n\n
\nPain Interference: IN THE PAST 7 DAYS - How much did pain interfere in\nyour day to day activities?\n\n
\nPain Interference: IN THE PAST 7 DAYS - How much did pain interfere with\nyour work around the house?\n\n
\nPain Interference: IN THE PAST 7 DAYS - How much did pain interfere with\nyour ability to participate in social activities?\n\n
\nPain Interference: IN THE PAST 7 DAYS - How much did pain interfere with\nyour household chores?\n\n
\nPain Intensity: How would you rate your pain on average? \n\n
\nToday my mood is changeable.\n\n
\nComplaining\n\n
\nToday I feel irritable.\n\n
\nToday I feel like a capable person.\n\n
\nToday I feel like people are out to get me.\n\n
\nToday I actually feel great inside.\n\n
\nToday I feel impulsive.\n\n
\nToday I feel depressed.\n\n
\nToday my thoughts are going fast.\n\n
\nToday it seems like nothing will ever work out for me.\n\n
\nToday I feel overactive.\n\n
\nToday I feel as if the world is against me.\n\n
\nJealous\n\n
\nToday I feel "sped up" inside.\n\n
\nToday I feel restless.\n\n
\nToday I feel argumentative.\n\n
\nToday I feel energized.\n\n
\nToday I feel.\n\n
\nProgress towards personal goals: In the past 3 months, I have come up with...\n\n
\nKnowledge: How much do you feel like you know about symptoms, treatment, coping strategies (coping methods), and medication? \n\n
\nInvolvement of family and friends in my mental health treatment: How much are family members, friends, boyfriend/girlfriend, and other people who are important to you (outside your mental health agency) involved in your mental health treatment? \n\n
\nContact with people outside of my family: In a normal week, how many times do you talk to someone outside of your family (like a friend, co-worker, classmate, roommate, etc.) \n\n
\nTime in structured roles: How much time do you spend working, volunteering, being a student, being a parent, taking care of someone else or someone else's house or apartment? That is, how much time do you spend in doing activities for or with\nanother person that are expected of you? (This would not include selfcare or personal home maintenance.) \n\n
\nSlow to forgive a wrong\n\n
\nSymptom distress: How much do your symptoms bother you? \n\n
\nImpairment of functioning: How much do your symptoms get in the way of you doing things that you would like to or need to do? \n\n
\nRelapse prevention planning: Which of the following would best describe what you know and what you have done in order not to have a relapse? \n\n
\nRelapse of symptoms: When is the last time you had a relapse of symptoms (that is, when your symptoms have gotten much worse)? \n\n
\nPsychiatric hospitalizations: When is the last time you have been hospitalized for mental health or substance abuse reasons? \n\n
\nCoping: How well do feel like you are coping with your mental or emotional illness from day to day? \n\n
\nInvolvement with self-help activities: How involved are you in consumer run services, peer support groups, Alcoholics Anonymous, drop-in centers, WRAP (Wellness Recovery Action Plan), or other similar self-help programs? \n\n
\nUsing medication effectively: (Don't answer this question if your doctor has not prescribed medication for you). How often do you take your medication as prescribed? \n\n
\nFunctioning affected by alcohol use: Drinking can interfere with functioning when it contributes to conflict in relationships, or to money, housing and legal concerns, to difficulty showing up at appointments or paying attention during them, or\nto increased symptoms. Over the past 3 months, how much did drinking get in the way of your functioning?\n\n
\nFunctioning affected by drug use: Using street drugs, and misusing prescription or over-the-counter medication can interfere with functioning when it contributes to conflict in relationships, or to money, housing and legal concerns, \nto difficulty showing up at appointments or paying attention during them, or to increased symptoms. Over the past 3 months, how much did drug use get in the way of your functioning? \n\n
\nSelf-punishing\n\n
\nRate your cough: 0 - I never cough TO 5 - I cough all the time\n\n
\nRate your phlegm: 0 - I have no phlegm (mucus) in my chest at all TO 5 - My chest is completely fully of phlegm (mucus)\n\n
\nRate the tightness of your chest: 0 - My chest does not feel tight at all TO 5 - My chest feels very tight\n\n
\nRate your breathlessness: 0 - When I walk up a hill or one flight of stairs I am not breathless TO 5 - When I walk up a hill or one flight of stairs I am very breathless\n\n
\nRate your activity limitation: 0 - I am not limited doing any activities at home TO 5 - I am very limited doing activities at home\n\n
\nRate your confidence: 0 - I am confident leaving my home despite my lung condition TO 5 - I am not at all confident leaving my home because of my lung condition\n\n
\nRate your sleep: 0 - I sleep soundly TO 5 - I don't sleep soundly because of my lung condition\n\n
\nMOOD-RELATED SIGNS: Anxiety; anxious expression, rumination, worrying\n\n
\nMOOD-RELATED SIGNS: Sadness; sad expression, sad voice, tearfulness\n\n
\nShy\n\n
\nMOOD-RELATED SIGNS: Lack of reaction to pleasant events\n\n
\nMOOD-RELATED SIGNS: Irritability; annoyed, short tempered\n\n
\nBEHAVIORAL DISTURBANCE: Agitation; restlessness, hand wringing, hair pulling\n\n
\nBEHAVIORAL DISTURBANCE: Retardation; slow movements, slow speech,\n slow reaction\n\n
\nBEHAVIORAL DISTURBANCE: Multiple physical complaints (score 0 if gastrointestinal symptoms only)\n\n
\nBEHAVIORAL DISTURBANCE: Loss of interest; less involved in usual activities\n(score 0 only if change occurred acutely, i.e., in less than one month)\n\n
\nPHYSICAL SIGNS: Appetite loss; eating less than usual\n\n
\nPHYSICAL SIGNS: Weight loss (score 2 if greater than 5 pounds in one month)\n\n
\nPHYSICAL SIGNS: Lack of energy; fatigues easily, unable to sustain activities\n\n
\nCYCLIC FUNCTIONS: Diurnal variation of mood; symptoms worse in the morning\n\n
\nPassive and unaggressive\n\n
\nCYCLIC FUNCTIONS: Difficulty falling asleep; later than usual for this individual\n\n
\nCYCLIC FUNCTIONS: Multiple awakenings during sleep\n\n
\nCYCLIC FUNCTIONS: Early morning awakening; earlier than usual for this individual\n\n
\nIDEATIONAL DISTURBANCE: Suicidal; feels life is not worth living\n\n
\nIDEATIONAL DISTURBANCE: Poor self-esteem; self-blame, self-depreciation, feelings of failure\n\n
\nIDEATIONAL DISTURBANCE: Pessimism; anticipation of the worst\n\n
\nIDEATIONAL DISTURBANCE: Mood congruent delusions; delusions of poverty, \nillness or loss\n\n
\nNOTES/CURRENT MEDICATIONS:(if none, type N/A and click Finish)\n\n
\nRate your energy: 0 - I have lots of energy TO 5 - I have no energy at all\n\n
\nMeek\n\n
\nStatus at Evaluation:\n\n
\nSpecify (then proceed to next question)\n\n
\nWorry: Worry about physical health.\n\n
\nWorry: Worry about cognitive performance (failing memory, getting lost when out, not able to follow conversation).\n\n
\nWorry: Worry over finances, family problems, physical health of relatives.\n\n
\nWorry: Worry associated with false belief and/or perception.\n\n
\nWorry: Worry over trifles (repeatedly calling for attention over trivial matters).\n\n
\nApprehension and Vigilance: Frightened and anxious (keyed up and on the edge).\n\n
\nApprehension and Vigilance: Sensitivity to noise (exaggerated startle response).\n\n
\nApprehension and Vigilance: Sleep disturbance (trouble with falling or staying asleep).\n\n
\nDependent\n\n
\nApprehension and Vigilance: Irritability (more easily annoyed than usual, short tempered and angry outbursts).\n\n
\nMotor Tension: Trembling.\n\n
\nMotor Tension: Motor tension (complain of headache, other body aches and pains).\n\n
\nMotor Tension: Restlessness (fidgeting, cannot sit still, pacing, wringing hands, picking clothes).\n\n
\nMotor Tension: Fatigability, tiredness.\n\n
\nAutonomic Hypersensitivity: Palpitations (complains of heart racing or thumping).\n\n
\nAutonomic Hypersensitivity: Dry mouth (not due to medication) sinking feeling in the stomach.\n\n
\nAutonomic Hypersensitivity: Hyperventilating, shortness of breath (even when not exerting).\n\n
\nAutonomic Hypersensitivity: Dizziness or light-headedness (complains as if going to faint).\n\n
\nAutonomic Hypersensitivity: Sweating, flushes or chills, tingling or numbness of fingers and toes.\n\n
\nHow many drinks containing alcohol did you have on a typical day when\nyou were drinking in the past year?\n\n
\nWants to be led\n\n
\n(Fears which are excessive, that do not make sense and tends to avoid - like afraid of crowds, going out alone, being in a small room, or being frightened by some kind of animals, heights, etc.). \nDescribe and then proceed to the next question. Or if no panic attacks to report, type 'N/A' and proceed to next question.\n\n
\n(Feelings of anxiety or dread that are so strong that they think they are going to die or have a heart attack and they simply have to do something to stop them, like immediately leaving the place, phoning relatives, etc.). \nDescribe and then proceed to the next question. Or if no panic attacks to report, type 'N/A' and proceed to next question.\n\n
\nPlease select the primary area where you have pain: (this question is REQUIRED)\n\n
\nI've been feeling optimistic about the future.\n\n
\nI've been feeling useful.\n\n
\nI've been feeling relaxed.\n\n
\n I've been dealing with problems well.\n\n
\nI've been thinking clearly.\n\n
\nI've been feeling close to other people.\n\n
\n I've been able to make up my own mind about things.\n\n
\nLets others make decisions\n\n
\nI still grow and change in positive ways despite my mental health problem.\n\n
\nEven though I may still have problems, I value myself as a person of worth.\n\n
\nI understand myself and have a good sense of who I am.\n\n
\nI feel good about myself.\n\n
\nThe way I think about things helps me to achieve my goals.\n\n
\nI feel at peace with myself.\n\n
\nI maintain a positive attitude for weeks at a time.\n\n
\nEvery day that I get up, I do something productive.\n\n
\nI am making progress toward my goals.\n\n
\nI engage in work or other activities that enrich myself and the world around me.\n\n
\nEasily fooled\n\n
\nAm terrified about being overweight.\n\n
\nAvoid eating when I am hungry.\n\n
\n Find myself preoccupied with food.\n\n
\nHave gone on eating binges where I feel that I may not be able to stop.\n\n
\nCut my food into small pieces.\n\n
\nAware of the calorie content of food that I eat.\n\n
\nParticularly avoid food with a high carbohydrate content (i.e., bread, rice, potatoes, etc.).\n\n
\nFeel that others would prefer if I ate more.\n\n
\nVomit after I have eaten.\n\n
\nFeel extremely guilty after eating.\n\n
\nToo easily influenced by friends\n\n
\nAm preoccupied with a desire to be thinner.\n\n
\nThink about burning up calories when I exercise.\n\n
\nOther people think that I am too thin.\n\n
\nAm preoccupied with the thought of having fat on my body.\n\n
\nTake longer than others to eat my meals.\n\n
\nAvoid foods with sugar in them.\n\n
\nEat diet foods.\n\n
\nFeel that food controls my life.\n\n
\nDisplay self-control around food.\n\n
\nFeel that others pressure me to eat.\n\n
\nWill confide in anyone\n\n
\nGive too much time and thought to food.\n\n
\nFeel uncomfortable after eating sweets.\n\n
\nEngage in dieting behavior.\n\n
\nLike my stomach to be empty.\n\n
\nHave the impulse to vomit after meals.\n\n
\nEnjoy trying new rich foods.\n\n
\n Gone on eating binges where you feel that you may not be able to stop? (Defined as eating much | \n more than most people would under the same circumstances and feeling that eating is out of control.)\n\n
\n Ever made yourself sick (vomited) to control your weight or shape?\n\n
\n Ever used laxatives, diet pills or diuretics (water pills) to control \nyour weight or shape?\n\n
\n Exercised more than 60 minutes a day to lose or to control your weight?\n\n
\nFond of everyone\n\n
\n Lost 20 pounds or more in the past 6 months.\n\n
\nFeet:\n\n
\nCurrent Weight(lbs.):\n\n
\nHighest Weight(excluding pregnancy):\n\n
\nLowest Adult Weight:\n\n
\nIdeal Weight:\n\n
\nInches:\n\n
\nLikes everybody\n\n
\nDid a parent or other adult in the household often or very often...Swear at you, insult you, put you down, or humiliate you? | \nor Act in a way that made you afraid that you might be physically hurt?\n\n
\nDid a parent or other adult in the household often or very often....Push, grab, slap, or throw something at you? or Ever hit you | \nso hard that you had marks or were injured?\n\n
\n Did an adult person at least 5 years older than you ever...Touch or fondle you or have you touch their body in a sexual way? | \n or Attempt or actually have oral, anal, or vaginal intercourse with you?\n\n
\nDid you often or very often feel that...No one in your family loved you or thought you were important or special? or Your family | didn't look out for each other, feel close to each other, or support each other?\n\n
\nDid you often or very often feel that...You didn't have enough to eat, had to wear dirty clothes, and had no one to protect you? | \nor Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?\n\n
\nWere your parents ever separated or divorced?\n\n
\nWas your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, | \noften, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit at least a few minutes or | \nthreatened with a gun or knife?\n\n
\nDid you live with anyone who was a problem drinker or alcoholic or who used street drugs?\n\n
\n Was a household member depressed or mentally ill, or did a household member attempt suicide?\n\n
\nDid a household member go to prison? \n\n
\nForgives anything\n\n
\nConsidering only your own "feeling best" rhythm, at what time would you \nget up if you were entirely free to plan your day?\n\n
\nConsidering your only "feeling best" rhythm, at what time would you go to \nbed if you were entirely free to plan your evening?\n\n
\nAssuming normal circumstance, how easy do you find getting up in the \nmorning? \n\n
\nHow alert do you feel during the first half hour after having awakened in \nthe morning?\n\n
\nDuring the first half hour after having awakened in the morning, how \ntired to you feel?\n\n
\nYou have decided to engage in some physical exercise. A friend suggests \nthat you do this one hour twice a week and the best time for him is \n7:00-8:00 a.m. Bearing in mind nothing else but your own "feeling best" \nrhythm, how do you think you would perform?\n\n
\nAt what time in the evening do you feel tired and, as a result, in need \nof sleep?\n\n
\nYou wish to be at your peak performance for a test which you know is \ngoing to be mentally exhausting and lasting for two hours. You are \nentirely free to plan your day, and considering only your own "feeling \nbest" rhythm, which ONE of the four testing times would you choose?\n\n
\nOne hears about "morning" and "evening" types of people. Which ONE of \nthese types do you consider yourself to be?\n\n
\nWhen would you prefer to rise (provided you have a full day's work - 8 \nhours) if you were totally free to arrange your time?\n\n
\nOversympathetic\n\n
\nIf you always had to rise at 6:00 a.m., what do you think it would be \nlike?\n\n
\nHow long a time does it usually take before you "recover your senses" in \nthe morning after rising from a night's sleep?\n\n
\nPlease indicate to what extend you are a morning or evening active \nindividual.\n\n
\nIn the past 30 days, I have been unhappy because of my drinking or drug \nuse.\n\n
\n In the past 30 days, because of my drinking or drug use I have not eaten.\n\n
\nIn the past 30 days, I have failed to do what was expected of me because \nof my drinking or drug use.\n\n
\nIn the past 30 days, I have felt guilty or ashamed because of my drinking \nor drug use.\n\n
\nIn the past 30 days, I have taken foolish risks when I have been drinking \nor using drugs.\n\n
\nIn the past 30 days, when drinking or using drugs, I have done impulsive \nthings that I regretted later.\n\n
\nIn the past 30 days, I have been harmed by my drinking or drug use.\n\n
\nGenerous to a fault (too generous)\n\n
\nIn the past 30 days, I have had money problems because of my drinking or \ndrug use.\n\n
\nIn the past 30 days, my physical appearance has been harmed by my \ndrinking or drug use.\n\n
\nIn the past 30 days, my family has been hurt by my drinking or drug use.\n\n
\nIn the past 30 days, a friendship or close relationship has been damaged \nby my drinking or drug use.\n\n
\nIn the past 30 days, my drinking or drug use has gotten in the way of my \ngrowth as a person.\n\n
\nIn the past 30 days, my drinking or drug use has damaged my social life, \npopularity, and reputation.\n\n
\nIn the past 30 days, I have spent too much or lost a lot of money because \nof my drinking or drug use.\n\n
\nIn the past 30 days, I have had an accident while using or under the \ninfluence of alcohol or drugs.\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nHow often did you have six or more drinks on one occasion in the \npast year?\n\n
\nOverprotective of others\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nTries to be too successful\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nExpects everyone to admire him\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nSession number:\n\n
\nSession number:\n\n
\nManages others\n\n
\nDISORIENTATION. Verbal or behavioral manifestation of not being oriented to time or place or misperceiving persons in the environment.\n\n
\nINAPPROPRIATE BEHAVIOR. Behavior inappropriate to place and/or for the person; e.g., pulling at tubes or dressings, attempting to get out of bed when it is contraindicated, and the like.\n\n
\nINAPPROPRIATE COMMUNICATION. Behavior inappropriate to place and/or for the person; e.g., incoherence, non-communicativeness, nonsensical or unintelligible speech.\n\n
\nILLUSIONS/HALLUCINATIONS. Seeing or hearing things that are not there; \ndistortions of visual objects.\n\n
\nPSYCHOMOTOR RETARDATION. Delayed responsiveness; few or no spontaneous \nactions/words; e.g., when the patient is prodded, reaction is deferred \nand/or the patient is unarousable.\n\n
\nDRESSING|\nHow well are you able to manage dressing? By dressing, we mean laying out the clothes and|\nputting them on, including shoes, and fastening clothes. Would you say that you:\n\n
\nGROOMING|\nNow I have some questions about how you manage with grooming activities like combing your hair,| putting on makeup, shaving, and brushing your teeth. Would you say that you:\n\n
\nBATHING|\nHow well can you bathe or shower yourself? (Bathing or showering by yourself means running|\nthe water, taking the bath or shower without any help, and washing all parts of the body, including| our hair and face.) Would you say that you:\n\n
\nEATING|\nHow well can you manage eating by yourself? Eating by yourself means drinking and eating without|\nhelp from anybody else, but you can use special utensils and straws. It also means cutting most foods|\non your own. Would you say that you:\n\n
\nBED MOBILITY|\nHow well can you manage sitting up or moving around in bed? Would you say that you:\n\n
\nDictatorial\n\n
\nTRANSFERRING|\nHow well can you get in and out of a bed or chair? Would you say that you:\n\n
\nWALKING|\nHow well are you able to walk around, either without any help or with a cane or walker, but not| including a wheelchair? (If asked, clarify that independence in walking refers to the ability to walk| short distances around the house. Independence in walking does not include climbing stairs.) |\nWould you say that you:\n\n
\nBased on the descriptions above, select the level of behavior:\n\n
\nCOMMUNICATION|\nHow effective are you at making yourself understood? Would you say that on a regular basis you are:\n\n
\nTOILETING|\nHow well can you manage using the toilet? (Using the toilet independently includes|\nadjusting clothing, getting to and on the toilet, and cleaning one's self. If reminders|\nare needed to use the toilet this counts as some help.) Would you say that you:\n\n
\nMDS HC 2.0/CPS Cognitive Skill for Daily Decision Making\n\n
\nMDS 2.0/CPS: Short Term Memory (recall of what was learned or known)\n\n
\nSPECIAL TREATMENTS\n\n
\nCheck all that apply:\n\n
\nCLINICAL MONITORING\n\n
\nSomewhat snobbish\n\n
\nSPECIAL NURSING|\nIn order to code this item "yes," the person must receive either tube feeding only,|\nor a combination of other special treatment (2 in Q13) and clinical monitoring (2 in Q14)\n\n
\nNEUROMUSCULAR DIAGNOSIS\n\n
\non Functional Strengths/ADLs/Community Supports Plan/Supervision Implications\n\n
\nPlease select the sources of information that were used to determine the \npatient's ability to manage |their activities of daily living (dressing, \ngrooming, bathing, eating, walking, toileting, transferring, and bed \nmobility). |Check all that apply:\n\n
\nPhysical Well-Being\n\n
\nMental/Emotional Well-Being\n\n
\nLife: How is it to live your day-to-day life?\n\n
\nWrite a few words to capture your thoughts:\n\n
\nWhere I am Now\n\n
\nEgotistical and conceited\n\n
\nWhere I Want to Be\n\n
\nWhere I am Now\n\n
\nWhere I Want to Be\n\n
\nWhere I am Now\n\n
\nWhere I Want to Be\n\n
\nWhere I am Now\n\n
\nWhere I Want to Be\n\n
\nWhere I am Now\n\n
\nWhere I Want to Be\n\n
\nWhere I am Now\n\n
\nSelfish\n\n
\nWhere I Want to Be\n\n
\nWhere I am Now\n\n
\nWhere I Want to Be\n\n
\nWhere I am Now\n\n
\nWhere I Want to Be\n\n
\nWhere I am Now\n\n
\nWhere I Want to Be\n\n
\nNow that you have thought about what matters to you in all of these areas, what would your life look like if you had the health you want? What kind of activities would you be doing? Or how might you feel different?\n\n
\nWhat area might you focus on? What might get in the way? How might you start?\n\n
\nAfter completing the Personal Health Inventory, talk to a friend, a \nfamily member, your health coach, a peer, or someone on your healthcare \nteam about areas you would like to explore further.\n\n
\nCold and unfeeling\n\n
\nType of Evaluation\n\n
\nAnticipated Start Date\n\n
\nAnticipated Length of Service\n\n
\nPhysical Function: Are you able to do chores such as vacuuming or yard work?\n\n
\nPhysical Function: Are you able to go up and down stairs at a normal pace?\n\n
\nPhysical Function: Are you able to go for a walk of at least 15 minutes?\n\n
\nPhysical Function: Are you able to run errands and shop?\n\n
\nAnxiety: IN THE PAST 7 DAYS I felt fearful.\n\n
\nAnxiety: IN THE PAST 7 DAYS I found it hard to focus on anything other than my anxiety.\n\n
\nAnxiety: IN THE PAST 7 DAYS my worries overwhelmed me.\n\n
\nSarcastic\n\n
\nAnxiety: IN THE PAST 7 DAYS I felt uneasy.\n\n
\nDepression: IN THE PAST 7 DAYS I felt worthless.\n\n
\nDepression: IN THE PAST 7 DAYS I felt helpless.\n\n
\nDepression: IN THE PAST 7 DAYS I felt depressed.\n\n
\nDepression: IN THE PAST 7 DAYS I felt hopeless.\n\n
\nFatigue: DURING THE PAST 7 DAYS I feel fatigued.\n\n
\nFatigue: DURING THE PAST 7 DAYS I have trouble starting things because I am tired.\n\n
\nFatigue: DURING THE PAST 7 DAYS how run-down did you feel on average?\n\n
\nFatigue: DURING THE PAST 7 DAYS how fatigued were you on average?\n\n
\nSleep Disturbance: IN THE PAST 7 DAYS my sleep quality was\n\n
\nHow often did you have a drink containing alcohol in the past year?\n \n\n
\nCruel and unkind\n\n
\nSleep Disturbance: IN THE PAST 7 DAYS my sleep was refreshing.\n\n
\nSleep Disturbance: IN THE PAST 7 DAYS I had a problem with my sleep.\n\n
\nSleep Disturbance: IN THE PAST 7 DAYS I had difficulty falling asleep.\n\n
\nAbility to Participate in Social Roles and Activities: I have trouble doing all of my regular leisure activities with others.\n\n
\nAbility to Participate in Social Roles and Activities: I have trouble doing all of the family activities that I want to do.\n\n
\nAbility to Participate in Social Roles and Activities: I have trouble doing all of my usual work (include work at home).\n\n
\nAbility to Participate in Social Roles and Activities: I have trouble doing all of the activities with friends that I want to do.\n\n
\nPain Interference: IN THE PAST 7 DAYS how much did pain interfere with your day to day activities?\n\n
\nPain Interference: IN THE PAST 7 DAYS how much did pain interfere with work around the home?\n\n
\nPain Interference: IN THE PAST 7 DAYS how much did pain interfere with your ability to participate in social activities?\n\n
\nFrequently angry\n\n
\nPain Interference: IN THE PAST 7 DAYS how much did pain interfere with your household chores?\n\n
\nCognitive Function - Abilities: IN THE PAST 7 DAYS I have been able to concentrate.\n\n
\nCognitive Function - Abilities: IN THE PAST 7 DAYS I have been able to remember to do things, like take medicine or buy something I needed.\n\n
\nPain Intensity: IN THE PAST 7 DAYS how would you rate your pain on average?\n\n
\nI have contact information for at least one health care professional (such as doctor or therapist) whom I can call during a suicidal crisis.\n\n
\nI cannot do anything to control my suicidal thoughts.\n\n
\nI know which friends and/or family members to contact to help take my mind off my suicidal feelings.\n\n
\nI know the nearest hospital or urgent care facility where I can go if I cannot handle my suicidal feelings.\n\n
\nWhen I feel suicidal, there are places I can go (such as a coffee shop, the gym, place of worship, or shopping mall) to help me take my mind off my problems.\n\n
\nI have several things I can do to get through a suicidal crisis.\n\n
\nHard-hearted\n\n
\nI am able to confide in someone, such as a friend, family member, supervisor, or spiritual advisor when I am experiencing a crisis.\n\n
\nSeeking help from health care professionals is a good way to keep myself safe when I am feeling suicidal.\n\n
\nI know it is important to limit access to weapons or other ways to hurt myself when I am feeling suicidal.\n\n
\nEven if I am alone, there are things I can do to take mind off my suicidal feelings and thoughts for at least a while.\n\n
\nI do not think there is anything that I can do to help myself when I am feeling suicidal.\n\n
\nIt is useless to talk to anyone about my suicidal thoughts.\n\n
\nWhen I am suicidal, I know of things to do by myself that help me feel less suicidal.\n\n
\nI can distract myself by doing other things or thinking about other things when I am feeling suicidal.\n\n
\nIf one way of trying to cope with suicidal feelings does not work, I have other ways to try.\n\n
\nI am at the mercy of my suicidal thoughts.\n\n
\nResentful\n\n
\nI feel that I have no one to turn to when I am feeling suicidal.\n\n
\nI see problems as a threat to my well-being.\n\n
\nI often doubt my capacity to solve problems.\n\n
\nOften before even trying to find a solution, I tell myself that it is difficult to solve problems.\n\n
\nMy problems often seem insurmountable.\n\n
\nWhen I attempt to solve a problem, I often question my abilities.\n\n
\nI often have the impression that my problems cannot be solved.\n\n
\nEven if I manage to find some solutions to my problems, I doubt that they will be easily resolved.\n\n
\nI have a tendency to see problems as a danger.\n\n
\nMy first reaction when faced with a problem is to question my abilities.\n\n
\nRebels against everything\n\n
\nI often see my problems as bigger than they really are.\n\n
\nEven if I have looked at a problem from all possible angles, I still wonder if the solution I decided on will be effective.\n\n
\nI consider problems to be obstacles that interfere with my functioning.\n\n
\nI had trouble in my romantic relationship with my spouse or partner.\n\n
\nI had trouble in my relationship with my children.\n\n
\nI had trouble with my family relationships.\n\n
\nI had trouble with my friendships and socializing.\n\n
\nI had trouble at work.\n\n
\nI had trouble with my training and education.\n\n
\nI had trouble with day to day activities, such as doing household chores, running errands and managing my medical care.\n\n
\nStubborn\n\n
\nCAT Responses\n\n
\nWhen working or looking for a job, I am respectful towards who I am.\n\n
\nI am worthy of working in a good job.\n\n
\nI am capable of working in a good job.\n\n
\nI have the strength to overcome any obstacles when it comes to working.\n\n
\nI am going to be working in a career job.\n\n
\nI feel energized when I think about future achievement with my job.\n\n
\nI am aware of what my skills are to be employed in a good job.\n\n
\nI am aware of what my resources are to be employed in a good job.\n\n
\nI am able to utilize my skills to move toward career goals.\n\n
\nDistrusts everybody\n\n
\nI am able to utilize my resources to move toward career goals.\n\n
\nI am on the road toward my career goals.\n\n
\nI am in the process of moving forward toward reaching my goals.\n\n
\nEven if I am not able to achieve my financial goals right away, I will find a way to get there.\n\n
\nMy current path will take me to where I need to be in my career.\n\n
\nHaving less than high school education\n\n
\nWork limiting health conditions (illness / injury)\n\n
\nLack of adequate job skills\n\n
\nLack of job experience\n\n
\nTransportation\n\n
\nTimid\n\n
\nChild care\n\n
\nRacial discrimination\n\n
\nLack of information about jobs\n\n
\nLack of stable housing\n\n
\nDrug / alcohol addiction\n\n
\nDomestic violence\n\n
\nPhysical disabilities\n\n
\nMental illness\n\n
\nFear of rejection\n\n
\nLack of work clothing\n\n
\nAlways ashamed of self\n\n
\nNo jobs in the community\n\n
\nNo jobs that match my skills / training\n\n
\nBeing a single parent\n\n
\nNeed to take care of young children\n\n
\nCannot speak English very well\n\n
\nCannot read or write very well\n\n
\nProblems with getting to job on time\n\n
\nLack of confidence\n\n
\nLack of support system\n\n
\nLack of coping skills for daily struggles\n\n
\nObeys too willingly\n\n
\nAnger management\n\n
\nPast criminal record\n\n
\nFully satisfied with how things are going in these aspects of life?\n\n
\nRegularly involved in all aspects of life that are important to you?\n\n
\nFunctioning your best in aspects of life that you do participate in?\n\n
\nHow often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?\n\n
\nHow often do you leave your seat in meetings or other situations in which you are expected to remain seated?\n\n
\nHow often do you have difficulty unwinding and relaxing when you have time to yourself?\n\n
\nWhen you're in a conversation, how often do you find yourself finishing the sentences of the people you are talking to before they can finish them themselves?\n\n
\nHow often do you put things off until the last minute?\n\n
\nHow many drinks containing alcohol did you have on a typical day when\nyou were drinking in the past year?\n \n\n
\nSpineless\n\n
\nHow often do you depend on others to keep your life in order and attend to details?\n\n
\nI found myself getting angry at people or situations.\n\n
\nWhen I got angry, I got really mad.\n\n
\nWhen I got angry, I stayed angry.\n\n
\nWhen I got angry at someone I wanted to hit them.\n\n
\nMy anger prevented me from getting along with people as well as I"_$C(146)_"d have liked to.\n\n
\nHave you been deliberately trying to limit the amount of food you eat to influence your shape or weight (whether or not you have succeeded)?\n\n
\nHave you gone for long periods of time (8 waking hours or more) without eating anything at all in order to influence your shape or weight?\n\n
\nHave you tried to exclude from your diet any foods that you like in order to influence your shape or weight (whether or not you have succeeded)?\n\n
\nHave you tried to follow definite rules regarding your eating (for example, a calorie limit) in order to influence your shape or weight (whether or not you have succeeded)?\n\n
\nHardly ever talks back\n\n
\nHave you had a definite desire to have an empty stomach with the aim of influencing your shape or weight?\n\n
\nHave you had a definite desire to have a totally flat stomach?\n\n
\nHas thinking about food, eating or calories made it very difficult to concentrate on things you are interested in (for example, working, following a conversation, or reading)?\n\n
\nHas thinking about shape or weight made it very difficult to concentrate on things you are interested in (for example, working, following a conversation, or reading)?\n\n
\nHave you had a definite fear of losing control over eating?\n\n
\nHave you had a definite fear that you might gain weight?\n\n
\nHave you felt fat?\n\n
\nHave you had a strong desire to lose weight?\n\n
\nOver the past 28 days, how many times have you eaten what other people would regards as an unusually large amount of food (given the circumstances)?\n\n
\n... On how many of these times did you have a sense of having lost control over your eating (at the time you were eating)?\n\n
\nClinging vine\n\n
\nOver the past 28 days, on how many DAYS have such episodes of overeating occurred (i.e. you have eaten an unusually large amount of food and have had a sense of loss of control at the time)?\n\n
\nOver the past 28 days, how many times have you made yourself sick (vomit) as a means of controlling your shape or weight?\n\n
\nOver the past 28 days, how many times have you taken laxatives as a means of controlling your shape or weight?\n\n
\nOver the past 28 days, how many times have you exercised in a "_$C(147)_"driven"_$C(148)_" or "_$C(147)_"compulsive"_$C(148)_" way as a means of controlling your weight, shape or amount of fat, or to burn off calories?\n\n
\nOver the past 28 days, on how many days have you eaten in secret (ie, furtively)?\n| ... Do not count episodes of binge eating\n\n
\nOn what proportion of the times that you have eaten have you felt guilty (felt that you've done wrong) because of its effect on your shape or weight? \n| ... Do not count episodes of binge eating.\n\n
\nHow concerned have you been about other people seeing you eat?\n|... Do not count episodes of binge eating\n\n
\nHas your weight influenced how you think about (judge) yourself as a person?\n\n
\nHas your shape influenced how you think about (judge) yourself as a person?\n\n
\nHow much would it have upset you if you had been asked to weigh yourself once a week (no more, or less, often) for the next four weeks?\n\n
\nLikes to be taken care of\n\n
\nHow dissatisfied have you been with your weight?\n\n
\nHow dissatisfied have you been with your shape?\n\n
\nHow uncomfortable have you felt seeing your body (for example, seeing your shape in the mirror, in a shop window reflection, while undressing or taking a bath or shower)?\n\n
\nHow uncomfortable have you felt about others seeing your shape or figure (for example, in communal changing rooms, when swimming, or wearing tight clothes)?\n\n
\nWhat is your weight at present? (Please give your best estimate.)\n\n
\nWhat is your height? (Please give your best estimate.)\n\n
\nIf female: Over the past three to four months have you missed any menstrual periods?\n\n
\nIf so, how many?\n\n
\n|Have you been taking the "pill"?\n\n
\n... made it difficult to concentrate?\n\n
\nWill believe anyone\n\n
\n... made you feel critical of yourself?\n\n
\n... stopped you going out with others?\n\n
\n... affected your work performance (if applicable)?\n\n
\n... made you forgetful?\n\n
\n... affected your ability to make everyday decisions?\n\n
\n... interfered with meals with family or friends?\n\n
\n... made you upset?\n\n
\n... made you feel ashamed of yourself?\n\n
\n... made it difficult to eat out with others?\n\n
\n... made you feel guilty?\n\n\n
\nWants everyone's love\n\n
\n... interfered with you doing things you used to enjoy?\n\n
\n... made you absent-minded?\n\n
\n... made you feel a failure?\n\n
\n... interfered with your relationships with others?\n\n
\n... made you worry?\n\n
\nAgrees with everyone\n\n
\nRead newspaper or magazine articles\n\n
\nRead mail\n\n
\nFriendly all the time\n\n
\nRead small print on package labels\n\n
\nKeep your place while reading\n\n
\nHandle finances\n\n
\nTake a message\n\n
\nEat and drink neatly\n\n
\nPrepare meals\n\n
\nRead menus\n\n
\nGroom yourself\n\n
\nIdentify medicine\n\n
\nTell time\n\n
\nLoves everyone\n\n
\nUse appliance dials\n\n
\nFind something on a crowded shelf\n\n
\nWatch TV\n\n
\nRead print on TV\n\n
\nSee photos\n\n
\nGet around outdoors in places you know\n\n
\nRead street signs\n\n
\nAdjust to bright light\n\n
\nCheck the highest consecutive level of disability:\n\n
\nIn general, would you say your health is:\n\n
\nToo lenient with others\n\n
\nIn general, would you say your quality of life is:\n\n
\nIn general, how would you rate your physical health?\n\n
\nIn general, how would you rate your mental health, including your mood and your ability to think?\n\n
\nIn general, how would you rate your satisfaction with your social activities and relationships?\n\n
\nIn general, please rate how well you carry out your usual social activities and roles. (This includes activities at home, at work and in your community, and responsibilities as a parent, child, spouse, employee, friend, etc.)\n\n
\nTo what extent are you able to carry out your everyday physical activities such as walking, climbing stairs, carrying groceries, or moving a chair?\n\n
\nIn the past 7 days... How often have you been bothered by emotional problems such as feeling anxious, depressed or irritable?\n\n
\nHow would you rate your fatigue on average?\n\n
\nHow would you rate your pain on average?\n\n
\nPlease list current medication and total daily doses below: \n\n
\nHow often did you have six or more drinks on one occasion in the past year?\n \n\n
\nTries to comfort everyone\n\n
\nI felt sleepy during the day\n\n
\nLevel of distress for "I felt sleepy during the day"\n\n
\nI felt drugged or like a zombie\n\n
\nLevel of distress for "I felt drugged or like a zombie"\n\n
\nI felt dizzy when I stood up and/or have fainted\n\n
\nLevel of distress for "I felt dizzy when I stood up and/or have fainted"\n\n
\nI have felt my heart beating irregularly or unusually fast\n\n
\nLevel of distress for "I have felt my heart beating irregularly or unusually fast"\n\n
\nMy muscles have been tense or jerky\n\n
\nLevel of distress for "My muscles have been tense or jerky"\n\n
\nToo willing to give to others\n\n
\nMy hands or arms have been shaky\n\n
\nLevel of distress for "My hands or arms have been shaky"\n\n
\nMy legs have felt restless and/or I couldn't sit still\n\n
\nLevel of distress for "My legs have felt restless and/or I couldn't sit still"\n\n
\nI have been drooling\n\n
\nLevel of distress for "I have been drooling"\n\n
\nMy movements or walking have been slower than usual\n\n
\nLevel of distress for "My movements or walking have been slower than usual"\n\n
\nI have had uncontrollable movements of my face or body\n\n
\nLevel of distress for " I have had uncontrollable movements of my face or body"\n\n
\nSpoils people with kindness\n\n
\nMy vision has been blurry\n\n
\nLevel of distress for "My vision has been blurry"\n\n
\nMy mouth has been dry\n\n
\nLevel of distress for "My mouth has been dry"\n\n
\nI have had difficulty passing urine\n\n
\nLevel of distress for "I have had difficulty passing urine"\n\n
\nI have felt like I am going to be sick or have vomited\n\n
\nLevel of distress for "I have felt like I am going to be sick or have vomited"\n\n
\nI have wet the bed\n\n
\nLevel of distress for "I have wet the bed"\n\n
\nSelect the statement you more strongly believe\n\n
\nI have been very thirsty and/or passing urine frequently\n\n
\nLevel of distress for "I have been very thirsty and/or passing urine frequently"\n\n
\nThe areas around my nipples have been sore and swollen\n\n
\nLevel of distress for "The areas around my nipples have been sore and swollen"\n\n
\nI have noticed fluid coming from my nipples\n\n
\nLevel of distress for "I have noticed fluid coming from my nipples"\n\n
\nI have had problems enjoying sex\n\n
\nLevel of distress for "I have had problems enjoying sex"\n\n
\nMen only: I have had problems getting an erection\n\n
\nLevel of distress for "Men only: I have had problems getting an erection"\n\n
\nSelect the statement you more strongly believe\n\n
\nWomen only: I have noticed a change in my periods\n\n
\nLevel or distress for "I have noticed a change in my periods"\n\n
\nMen and women: I have been gaining weight\n\n
\nLevel of distress for "I have been gaining weight"\n\n
\nSelect the statement you more strongly believe\n\n
\nSelect the statement you more strongly believe\n\n
\nScope places out before entering\n\n
\nSit with back to wall\n\n
\nRush through stores or go directly to desired items and leave as quickly as possible\n\n
\nCheck yard or the area around your home ("Perimeter Checks")\n\n\nMake up contingency plans in case someone is physically aggressive or there is some kind of emergency\n\n
\nWalk slowly to let someone pass who is close behind\n\n
\nSelect the statement you more strongly believe\n\n
\nWatch others for signs of danger\n\n
\nCheck locks on doors or windows\n\n
\nOver-plan for everyday events\n\n
\nCall or contact loved ones to make sure they are ok\n\n
\nProcrastinate before I start something or make a decision\n\n
\nResearch things before I start or before making a decision\n\n
\nTry to do things perfectly\n\n
\nMonitor the clock\n\n
\nAsk others for reassurance (e.g., about a decision or worry)\n\n
\nMonitor others' reactions to things I say\n\n
\nSelect the statement you more strongly believe\n\n
\nPrepare things to say while others are talking\n\n
\nTalk through silences or talk so that silences do not occur\n\n
\nBe overly polite or agreeable\n\n
\nAttempt to hide anxiety (e.g., put hands in pocket because they are shaking)\n\n
\nLeave events or activities early\n\n
\nMake little eye contact\n\n
\nRespond to calls with text messages\n\n
\nPlan and/or rehearse what I am going to say ahead of time\n\n
\nMake myself look busy while at work or when out in public so that others do not talk to me\n\n
\nCut conversations short\n\n
\nSelect the statement you more strongly believe\n\n
\nMonitor what I say in conversations\n\n
\nPretend I do not see or recognize someone so that I do not have to speak with them\n\n
\nTake it easy when I exercise (or do other activities that require physical exertion) so my heart rate does not get too high\n\n
\nStay on the outside of crowds and/or monitor for exits or escape routes\n\n
\nCarry a medication in case I need it\n\n
\nCheck my pulse or heart rate\n\n
\nCheck that I can swallow without choking\n\n
\nStay within certain distances from home (or other safe places)\n\n
\nPay attention to body for physical symptoms or sensations\n\n
\nCall doctors' offices (or health-lines) frequently\n\n
\nHow often do you have a drink containing alcohol?\n \n\n
\nSelect the statement you more strongly believe\n\n
\nCheck my body for problems (pain, discomfort, symmetry, discoloration, new growth, etc.)\n\n
\nResearch medical symptoms on the internet\n\n
\nCheck my body temperature\n\n
\nTalk to others about my health or health-related activities\n\n
\nRequest specialized medical exams from providers\n\n
\nScope places out before entering\n\n
\nSit with back to wall\n\n
\nCheck yard or the area around your home ("Perimeter Checks")\n\n\nMake up contingency plans in case someone is physically aggressive or there is some kind of emergency\n\n
\nWalk slowly to let someone pass who is close behind\n\n
\nSelect the statement you more strongly believe\n\n
\nWatch others for signs of danger\n\n
\nCheck locks on doors or windows\n\n
\nPretend I do not see or recognize someone so that I do not have to speak with them\n\n
\nCut conversations short\n\n
\nLeave events or activities early\n\n
\nSelect the statement you more strongly believe\n\n
\nHave you had at least one experience like this that troubles you currently?\n\n
\nIf yes, please check the type of experience that is most currently distressing. If more than one, check all that apply.\n\n
\nI blame myself.\n\n
\nI have lost faith in humanity.\n\n
\nPeople would hate me if they really knew me.\n\n
\nI have trouble seeing goodness in others.\n\n
\nPeople don't deserve second chances.\n\n
\nI am disgusted by what happened.\n\n
\nSelect the statement you more strongly believe\n\n
\nI feel like I don't deserve a good life.\n\n
\nI keep myself from having success.\n\n
\nI no longer believe there is a higher power.\n\n
\nI lost trust in others.\n\n
\nI am angry all the time.\n\n
\nI am not the good person I thought I was.\n\n
\nI have lost pride in myself.\n\n
\nI cannot be honest with other people.\n\n
\nRomantic relationships with spouse or partner \n\n
\nRelationships with your children\n\n
\nSelect the statement you more strongly believe\n\n
\nRelationships with other family members \n\n
\nFriendships or socializing\n\n
\nProfessional (work, education, training) \n\n
\nHobbies and recreation activities that you do alone\n\n
\nHobbies and recreation activities that you do with others\n\n
\nReligious faith/spirituality\n\n
\nDay to day activities, such as chores, errands, finances, health\n\n
\nOn how many days in the last 3 months did you miss work or school because of your headaches?\n\n
\nHow many days in the last 3 months was your productivity at work or school reduced by half or more because of your headaches? (Do not include days you counted in question 1 where you missed work or school.)\n\n
\nOn how many days in the last 3 months did you not do household work (such as housework, home\nrepairs and maintenance, shopping, caring for children and relatives) because of your headaches?\n\n
\nSelect the statement you more strongly believe\n\n
\nHow many days in the last 3 months was your productivity in household work reduced by half of more because of your headaches? (Do not include days you counted in question 3 where you did not do household work.)\n\n
\nOn how many days in the last 3 months did you miss family, social or leisure activities because of your headaches?\n\n
\nOn how many days in the last 3 months did you have a headache? (If a headache lasted more than 1 day, count each day.)\n\n
\nOn a scale of 0 - 10, on average how painful were these headaches?\n (where 0 = no pain at all, and 10 = pain as bad as it can be.)\n\n
\nWhen you have headaches, how often is the pain severe?\n\n
\nHow often do headaches limit your ability to do usual daily activities including household work, work, school, or social activities?\n\n
\nWhen you have a headache, how often do you wish you could lie down?\n\n
\nIn the past 4 weeks, how often have you felt too tired to do work or daily activities because of your headaches?\n\n
\nIn the past 4 weeks, how often have you felt fed up or irritated because of your headaches?\n\n
\nIn the past 4 weeks, how often did headaches limit your ability to concentrate on work or daily activities?\n\n
\nSelect the statement you more strongly believe\n\n
\nMy motivation is lower when I am fatigued.\n\n
\nExercise brings on my fatigue.\n\n
\nI am easily fatigued.\n\n
\nFatigue interferes with my physical functioning.\n\n
\nFatigue causes frequent problems for me.\n\n
\nSelect the statement you more strongly believe\n\n
\nMy fatigue prevents sustained physical functioning.\n\n
\nFatigue interferes with carrying out certain duties and responsibilities.\n\n
\nFatigue is among my three most disabling symptoms.\n\n
\nFatigue interferes with my work, family, or social life.\n\n
\nAre you ever troubled by breathlessness except on strenuous exertion?\n\n
\nAre you short of breath when hurrying on the level or walking up a slight hill?\n\n
\nDo you have to walk slower than most people on the level? -or-\n|Do you have to stop after a mile or so (or after 1/4 hour) on the level at your own pace?\n\n
\nDo you have to stop for breath after walking about 100 yds. (or after a few minutes) on the level?\n\n
\nAre you too breathless to leave the house, or breathless after undressing?\n\n
\nBreathlessness: At rest [Now]\n\n
\nSelect the statement you more strongly believe\n\n
\nBreathlessness: At rest [Pre-COVID]\n\n
\nBreathlessness: Changing position e.g. from lying to sitting or sitting to lying [Now]\n\n
\nBreathlessness: Changing position e.g. from lying to sitting or sitting to lying [Pre-COVID]\n\n
\nBreathlessness: On dressing yourself [Now]\n\n
\nBreathlessness: On dressing yourself [Pre-COVID]\n\n
\nBreathlessness: On walking up a flight of stairs [Now]\n\n
\nBreathlessness: On walking up a flight of stairs [Pre-COVID]\n\n
\nCough / throat sensitivity [Now]\n\n
\nCough / throat sensitivity [Pre-COVID]\n\n
\nChange of voice [Now]\n\n
\nSelect the statement you more strongly believe\n\n
\nChange of voice [Pre-COVID]\n\n
\nFatigue levels in your usual activities [Now]\n\n
\nFatigue levels in your usual activities [Pre-COVID]\n\n
\nAltered smell [Now]\n\n
\nAltered smell [Pre-COVID]\n\n
\nAltered taste [Now]\n\n
\nAltered taste [Pre-COVID]\n\n
\nChest pain [Now]\n\n
\nChest pain [Pre-COVID]\n\n
\nJoint pain [Now]\n\n
\nGlobal Judgments\n \nIncapacitation due to abnormal movements.\n \n\n
\nHow many drinks containing alcohol do you have on a typical day when\nyou are drinking?\n \n\n
\nSelect the statement you more strongly believe\n\n
\nJoint Pain [Pre-COVID]\n\n
\nMuscle pain [Now]\n\n
\nMuscle pain [Pre-COVID]\n\n
\nHeadache [Now]\n\n
\nHeadache [Pre-COVID]\n\n
\nAbdominal pain [Now]\n\n
\nAbdominal pain [Pre-COVID]\n\n
\nProblems with concentration [Now]\n\n
\nProblems with concentration [Pre-COVID]\n\n
\nProblems with memory [Now]\n\n
\nSelect the statement you more strongly believe\n\n
\nProblems with memory [Pre-COVID]\n\n
\nProblems with planning [Now]\n\n
\nProblems with planning [Pre-COVID]\n\n
\nPalpitations in certain positions, activity or at rest [Now]\n\n
\nPalpitations in certain positions, activity or at rest [Pre-COVID]\n\n
\nDizziness in certain positions, activity or at rest [Now]\n\n
\nDizziness in certain positions, activity or at rest [Pre-COVID]\n\n
\nCrashing or relapse hours or days after physical, cognitive or emotional exertion [Now]\n\n
\nCrashing or relapse hours or days after physical, cognitive or emotional exertion [Pre-COVID]\n\n
\nFeeling anxious [Now]\n\n
\nSelect the statement you more strongly believe\n\n
\nFeeling anxious [Pre-COVID]\n\n
\nFeeling depressed [Now]\n\n
\nFeeling depressed [Pre-COVID]\n\n
\nHaving unwanted memories of your illness or time in hospital [Now]\n\n
\nHaving unwanted memories of your illness or time in hospital [Pre-COVID]\n\n
\nHaving unpleasant dreams about your illness or time in hospital [Now]\n\n
\nHaving unpleasant dreams about your illness or time in hospital [Pre-COVID]\n\n
\nTrying to avoid thoughts or feelings about your illness or time in hospital [Now]\n\n
\nTrying to avoid thoughts or feelings about your illness or time in hospital [Pre-COVID]\n\n
\nSleep problems, such as difficulty falling asleep, staying asleep or oversleeping [Now]\n\n
\nSelect the statement you more strongly believe\n\n
\nSleep problems, such as difficulty falling asleep, staying asleep or oversleeping [Pre-COVID]\n\n
\nDifficulty with communication / word finding difficulty / understanding others [Now]\n\n
\nDifficulty with communication/word finding difficulty/understanding others [Pre-COVID]\n\n
\nDifficulties with walking or moving around [Now]\n\n
\nDifficulties with walking or moving around [Pre-COVID]\n\n
\nDifficulties with personal tasks such as using the toilet or getting washed and dressed [Now]\n\n
\nDifficulties with personal tasks such as using the toilet or getting washed and dressed [Pre-COVID]\n\n
\nDifficulty doing wider activities, such as household work, leisure/sporting activities, paid/unpaid work, study or shopping [Now]\n\n
\nDifficulty doing wider activities, such as household work, leisure/sporting activities, paid/unpaid work, study or shopping [Pre-COVID]\n\n
\nProblems with socializing / interacting with friends* or caring for dependants [Now]\n|* related to your illness and not due to social distancing / lockdown measures\n\n
\nSelect the statement you more strongly believe\n\n
\nProblems with socializing / interacting with friends* or caring for dependants [Pre-COVID]\n|* related to your illness and not due to social distancing / lockdown measures\n\n
\nPlease select any of the following symptoms you have experienced since your illness in the last 7 days. Please also select any previous problems that have worsened for you following your illness.\n\n
\nOther symptoms - free text\n\n
\nHow good or bad is your health overall in the last 7 days? [Now]\n\n
\nHow good or bad is your health overall in the last 7 days? [Pre-COVID]\n\n
\nOccupation\n\n
\nHas your COVID-19 illness affected your work?\n\n
\nAny other comments/concerns\n\n
\nThis is space for your partner, family or caregiver to add anything from their perspective\n\n
\nMOBILITY\n\n
\nSelect the statement you more strongly believe\n\n
\nSELF-CARE\n\n
\nUSUAL ACTIVITIES (e.g. work, study, housework, family or leisure activities)\n\n
\nPAIN / DISCOMFORT\n\n
\nANXIETY / DEPRESSION\n\n
\nYOUR HEALTH TODAY\n\n
\nCan you live alone without any assistance from another person? (e.g. independently being able to eat, walk, use the toilet and manage routine daily hygiene)\n\n
\nAre there duties/activities at home or at work which you are no longer able to perform yourself?\n\n
\nDo you suffer from symptoms, pain, depression or anxiety?\n\n
\nDo you need to avoid or reduce duties/activities or spread these over time?\n\n
\nSelect the statement you more strongly believe\n\n
\nSelect the statement you more strongly believe\n\n
\nYou felt so good or so hyper that other people thought you were not your normal self or you|\nwere so hyper that you got into trouble?\n\n
\nYou were so irritable that you shouted at people or started fights or arguments?\n\n
\nYou felt much more self-confident than usual?\n\n
\nYou got much less sleep than usual and found that you didn't really miss it?\n\n
\nYou were more talkative or spoke much faster than usual?\n\n
\nThoughts raced through your head or you couldn't slow your mind down?\n\n
\nSelect the statement you more strongly believe\n\n
\nYou were so easily distracted by things around you that you had trouble concentrating or|\nstaying on track?\n\n
\nYou had more energy than usual?\n\n
\nYou were much more active or did many more things than usual?\n\n
\nYou were much more social or outgoing than usual, for example, you telephoned friends|\nin the middle of the night?\n\n
\nYou were much more interested in sex than usual?\n\n
\nYou did things that were unusual for you or that other people might have thought were|\nexcessive, foolish, or risky?\n\n
\nSpending money got you or your family in trouble?\n\n
\nIf you checked YES to more than one of the above, have several of these ever|\nhappened during the same period of time?\n\n
\nHow much of a problem did any of these cause you - like being unable to work;|\nhaving family, money, or legal troubles; getting into arguments or fights?\n\n
\nWhat number best describes your pain on average in the past week?\n\n
\nSelect the statement you more strongly believe\n\n
\nWhat number best describes how, during the past week, pain has interfered with your enjoyment of life?\n\n
\nWhat number best describes how, during the past week, pain has interfered with your general activity?\n\n
\nDate of administration:\n\n
\nMethod of administration:\n\n
\nSince the last session, how many days did you drink ANY alcohol?\n\n
\nSince the last session, how many days did you have at least 5 drinks (if you are a man) or at least 4 drinks (if you are a woman)? [One drink is considered one shot of hard liquor (1.5 oz.) or 12-ounce \ncan/bottle of beer or 5-ounce glass of wine.]\n\n
\nSince the last session, how many days did you use any illegal or street drugs or abuse any prescription medications?\n\n
\nMarijuana (cannabis, pot, weed)?\n\n
\nSedatives and/or Tranquilizers (benzos, Valium, Xanax, Ativan, Ambien, barbs, Phenobarbital, downers, etc.)?\n\n
\nCocaine and/or Crack?\n\n
\nHow often do you have six or more drinks on one occasion?\n \n\n
\nSelect the statement you more strongly believe\n\n
\nOther Stimulants (amphetamine, methamphetamine, Dexedrine, Ritalin, Adderall, speed, crystal meth, ice, etc.)?\n\n
\nOpiates (Heroin, Morphine, Dilaudid, Demerol, Oxycontin, oxy, codeine (Tylenol 2,3,4), Percocet, Vicodin, Fentanyl, etc.)?\n\n
\nInhalants (glues, adhesives, nail polish remover, paint thinner, etc.)?\n\n
\nOther drugs (steroids, non-prescription sleep and diet pills, Benadryl, Ephedra, other over-the-counter or unknown medications)?\n\n
\nDate of administration:\n\n
\nMethod of administration:\n\n
\nIn the past 30 days, how would you say your physical health has been?\n\n
\nIn the past 30 days, how much were you bothered by cravings or urges to drink alcohol or use drugs?\n\n
\nHow confident are you that you will NOT use alcohol and drugs in the next 30 days?\n\n
\nDoes your religion or spirituality help support your recovery?\n\n
\nSelect the statement you more strongly believe\n\n
\nDo you have enough income (from legal sources) to pay for necessities such as housing, transportation, food and clothing for yourself and your dependents?\n\n
\nIn the past 30 days, how much have you been bothered by arguments or problems getting along with any family members or friends?\n\n
\nHow satisfied are you with your progress toward achieving your recovery goals?\n\n
\nIn the past 30 days, how many nights did you have trouble falling asleep or staying asleep?\n\n
\nIn the past 30 days, how many days have you felt depressed, anxious, angry or very upset throughout most of the day?\n\n
\nIn the past 30 days, how many days did you drink ANY alcohol?\n\n
\nIn the past 30 days, how many days did you have at least 5 drinks (if you are a man) or at least 4 drinks (if you are a woman)? [One drink is considered one shot of hard liquor (1.5 oz.) or 12-ounce \ncan/bottle of beer or 5-ounce glass of wine.]\n\n
\nIn the past 30 days, how many days did you use any illegal or street drugs or abuse any prescription medications?\n\n
\nMarijuana (cannabis, pot, weed)?\n\n
\nSedatives and/or Tranquilizers (benzos, Valium, Xanax, Ativan, Ambien, barbs, Phenobarbital, downers, etc.)?\n\n
\nDo you ever have trouble finding time to get your hair\ncut or styled?\n\n
\nCocaine and/or Crack?\n\n
\nOther Stimulants (amphetamine, methamphetamine, Dexedrine, Ritalin, Adderall, speed, crystal meth, ice, etc.)?\n\n
\nOpiates (Heroin, Morphine, Dilaudid, Demerol, Oxycontin, oxy, codeine (Tylenol 2,3,4), Percocet, Vicodin, Fentanyl, etc.)?\n\n
\nInhalants (glues, adhesives, nail polish remover, paint thinner, etc.)?\n\n
\nOther drugs (steroids, non-prescription sleep and diet pills, Benadryl, Ephedra, other over-the-counter or unknown medications)?\n\n
\nIn the past 30 days, how many days did you attend self-help meetings like AA or NA to support your recovery?\n\n
\nIn the past 30 days, how many days were you in any situations or with any people that might put you at an increased risk for using alcohol or drugs (i.e., around risky "people, places or things")?\n\n
\nIn the past 30 days, how many days did you spend much of the time at work, school, or doing volunteer work?\n\n
\nIn the past 30 days, how many days did you contact or spend time with any family members or friends who are supportive of your recovery?\n\n
\nIn the past 30 days, on the days that you consumed alcohol, what was the average number of drinks you consumed on those days?\n\n
\nDoes college "stir you into action"?\n\n
\nIn the past 30 days, on the days that you consumed alcohol, what was the highest number of drinks you consumed in one day?\n\n
\nDate of administration:\n\n
\nMethod of administration:\n\n
\nIn the past 7 days, how would you say your physical health has been?\n\n
\nIn the past 7 days, how many nights did you have trouble falling asleep or staying asleep?\n\n
\nIn the past 7 days, how many days have you felt depressed, anxious, angry or very upset throughout most of the day?\n\n
\nIn the past 7 days, how many days did you drink ANY alcohol?\n\n
\nIn the past 7 days, how many days did you have at least 5 drinks (if you are a man) or at least 4 drinks (if you are a woman)? [One drink is considered one shot of hard liquor (1.5 oz.) or 12-ounce \ncan/bottle of beer or 5-ounce glass of wine.]\n\n
\nIn the past 7 days, how many days did you use any illegal or street drugs or abuse any prescription medications?\n\n
\nMarijuana (cannabis, pot, weed)?\n\n
\nIs your everyday life filled mostly by:\n\n
\nSedatives and/or Tranquilizers (benzos, Valium, Xanax, Ativan, Ambien, barbs, Phenobarbital, downers, etc.)?\n\n
\nCocaine and/or Crack?\n\n
\nOther Stimulants (amphetamine, methamphetamine, Dexedrine, Ritalin, Adderall, speed, crystal meth, ice, etc.)?\n\n
\nOpiates (Heroin, Morphine, Dilaudid, Demerol, Oxycontin, oxy, codeine (Tylenol 2,3,4), Percocet, Vicodin, Fentanyl, etc.)?\n\n
\nInhalants (glues, adhesives, nail polish remover, paint thinner, etc.)?\n\n
\nOther drugs (steroids, non-prescription sleep and diet pills, Benadryl, Ephedra, other over-the-counter or unknown medications)?\n\n
\nIn the past 7 days, how much were you bothered by cravings or urges to drink alcohol or use drugs?\n\n
\nHow confident are you in your ability to be completely abstinent (clean) from alcohol and drugs in the next 7 days?\n\n
\nIn the past 7 days, how many days did you attend self-help meetings like AA or NA to support your recovery?\n\n
\nIn the past 7 days, how many days were you in any situations or with any people that might put you at an increased risk for using alcohol or drugs (i.e., around risky "people, places or things")?\n\n
\nSome people live a calm, predictable life. Others find themselves\noften facing unexpected changes, frequent interruptions,\nInconveniences or "things going wrong." how often are you faced\nwith these minor (or major) annoyances or frustrations?\n\n
\nDoes your religion or spirituality help support your recovery?\n\n
\nIn the past 7 days, how many days did you spend much of the time at work, school, or doing volunteer work?\n\n
\nDo you have enough income (from legal sources) to pay for necessities such as housing, transportation, food and clothing for yourself and your dependents?\n\n
\nIn the past 7 days, how much have you been bothered by arguments or problems getting along with any family members or friends?\n\n
\nIn the past 7 days, how many days were you in contact or spent time with any family members or friends who are supportive of your recovery?\n\n
\nHow satisfied are you with your progress toward achieving your recovery goals?\n\n
\nIn the past 7 days, on the days that you consumed alcohol, what was the average number of drinks you consumed on those days?\n\n
\nIn the past 7 days, on the days that you consumed alcohol, what was the highest number of drinks you consumed in one day?\n\n
\nCursing or verbal aggression\n\n
\nHitting, kicking, pushing, biting, scratching, aggressive spitting\n\n
\nWhen you are under pressure or stress, do you usually:\n\n
\nGrabbing onto people, throwing, tearing, or destroying things\n\n
\nOther aggressive behaviors, including: intentional falling, making verbal/physical sexual advances, eating/drinking/chewing inappropriate substances, hurt self or other\n\n
\nPace, aimless wandering, trying to get to a different place (e.g. out of the room, building)\n\n
\nGeneral restlessness, repetitious mannerisms, tapping, strange movements\n\n
\nInappropriate dress or disrobing\n\n
\nHandling things inappropriately\n\n
\nConstant request for attention or help\n\n
\nRepetitive sentences, calls, questions, or words\n\n
\nComplaining, negativism, refusal to follow directions\n\n
\nStrange noises (weird laughter or crying)\n\n
\nOrdinarily, how rapidly do you eat?\n\n
\nHiding or hoarding things\n\n
\nScreaming\n\n
\nWord List Version\n\n
\nPerson's Answers\n\n
\nI can do some form of work, despite the pain ('work' includes housework, paid and unpaid work).\n\n\nI can live a normal lifestyle, despite the pain.\n\n
\nDoes the patient have false beliefs, such as thinking that others are stealing from him/her or planning to harm him/her in some way?\n\n
\nDelusions - SEVERITY\n\n
\nDelusions - DISTRESS\n\n
\nDoes the patient have hallucinations such as false visions or voices? Does he or she seem to hear or see things that are not present?\n\n
\nHas your spouse or some friend ever told you that you eat too fast?\n\n
\nHallucinations - SEVERITY\n\n
\nHallucinations - DISTRESS\n\n
\nIs the patient resistive to help from others at times, or hard to handle?\n\n
\nAgitation/Aggression - SEVERITY\n\n
\nAgitation/Aggression - DISTRESS\n\n
\nDoes the patient seem sad or say that he/she is depressed?\n\n
\nDepression/Dysphoria - SEVERITY\n\n
\nDepression/Dysphoria - DISTRESS\n\n
\nDoes the patient become upset when separated from you? Does he/she have any other signs of nervousness such as shortness of breath, sighing, being unable to relax, or feeling excessively tense?\n\n
\nAnxiety - SEVERITY\n\n
\nHow often do you find yourself doing more than one thing at a time,\nsuch as working while eating, reading while dressing, figuring\nout problems while driving?\n\n
\nAnxiety - DISTRESS\n\n
\nDoes the patient appear to feel too good or act excessively happy?\n\n
\nElation/Euphoria - SEVERITY\n\n
\nElation/Euphoria - DISTRESS\n\n
\nDoes the patient seem less interested in his/her usual activities or in the activities and plans of others?\n\n
\nApathy/Indifference - SEVERITY\n\n
\nApathy/Indifference - DISTRESS\n\n
\nDoes the patient seem to act impulsively, for example, talking to strangers as if he/she knows them, or saying things that may hurt people's feelings?\n\n
\nDisinhibition - SEVERITY\n\n
\nDisinhibition - DISTRESS\n\n
\nHow often during the last year have you found that you were not able to\nstop drinking once you had started?\n \n\n
\nWhen you listen to someone talking, and this person takes too\nlong to come to the point, do you feel like hurrying him along?\n\n
\nIs the patient impatient and cranky? Does he/she have difficulty coping with delays or waiting for planned activities?\n\n
\nIrritability/Lability - SEVERITY\n\n
\nIrritability/Lability - DISTRESS\n\n
\nDoes the patient engage in repetitive activities such as pacing around the house, handling buttons, wrapping string, or doing other things repeatedly?\n\n
\nMotor Disturbance - SEVERITY\n\n
\nMotor Disturbance - DISTRESS\n\n
\nDoes the patient awaken you during the night, rise too early in the morning, or take excessive naps during the day?\n\n
\nNighttime Behaviors - SEVERITY\n\n
\nNighttime Behaviors - DISTRESS\n\n
\nHas the patient lost or gained weight, or had a change in the type of food he/she likes?\n\n
\nHow often do you actually "put words in his mouth" in order\nto speed things up?\n\n
\nAppetite/Eating - SEVERITY\n\n
\nAppetite/Eating - DISTRESS\n\n
\nIf you had unwanted urges to gamble during the past WEEK, on average, how strong were your urges? Please select the most appropriate number.\n\n
\nDuring the past WEEK, how many times did you experience urges to gamble? Please select the most appropriate number.\n\n
\nDuring the past WEEK, how many hours (add up hours) were you preoccupied with your urges to gamble? Please select the most appropriate number.\n\n
\nDuring the past WEEK, how much were you able to control your urges? Please select the most appropriate number.\n\n
\nDuring the past WEEK, how often did thoughts about gambling and placing bets come up? Please select the most appropriate answer.\n\n
\nDuring the past WEEK, approximately how many hours (add up hours) did you spend thinking about gambling and thinking about placing bets? Please select the most appropriate number.\n\n
\nIf you tell your spouse or a friend that you will meet them somewhere\nat a definite time, how often do you arrive late?\n\n
\nDuring the past WEEK, how much were you able to control your thoughts of gambling? Please select the most appropriate number.\n\n
\nDuring the past WEEK, approximately how much total time did you spend gambling or on gambling related activities. Please select the most appropriate number.\n\n
\nDuring the past WEEK, on average, how much anticipatory tension and/or excitement did you have shortly before you engaged in gambling? If you did not actually gamble, please estimate how much tension and/or excitement you believe you would have experienced if you had gambled. Please select the most appropriate number.\n\n
\nDuring the past WEEK, on average, how much excitement and pleasure did you feel when you won on your bet. If you did not actually win at gambling, please estimate how much excitement and pleasure you would have experienced if you had won. Please select the most appropriate number.\n\n
\nDuring the past WEEK, how much emotional distress (mental pain or anguish, shame, guilt, embarrassment) has your gambling caused you? Please select the most appropriate number.\n\n
\nDuring the past WEEK, how much personal trouble (relationship, financial, legal, job, medical or health) has your gambling caused you? Please select the most appropriate number.\n\n
\nDuring the past 12 months, have you become restless irritable or anxious when trying to stop/cut down on gambling?\n\n
\nDuring the past 12 months, have you tried to keep your family or friends from knowing how much you gambled?\n\n
\nDuring the past 12 months did you have such financial trouble as a result of your gambling that you had to get help with living expenses from family, friends or welfare?\n\n
\nIn the last twelve months, did you use pot (cannabis), use another street drug, or use a prescription medication 'recreationally' (just for the feeling, or using more than prescribed)?\n\n
\nDo you find yourself hurrying to get places even when there\nIs plenty of time?\n\n
\nRepeated, disturbing, and unwanted memories of the stressful experience?\n\n
\nRepeated, disturbing dreams of the stressful experience?\n\n
\nSuddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?\n\n
\nFeeling very upset when something reminded you of the stressful experience?\n\n
\nHaving strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?\n\n
\nAvoiding memories, thoughts, or feelings related to the stressful experience?\n\n
\nAvoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?\n\n
\nTrouble remembering important parts of the stressful experience?\n\n
\nHaving 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)?\n\n
\nBlaming yourself or someone else for the stressful experience or what happened after it?\n\n
\nSuppose you are to meet someone at a public place (street corner,\nbuilding lobby, restaurant) and the other person is already\nget something done while waiting?\n\n
\nHaving strong negative feelings such as fear, horror, anger, guilt, or shame?\n\n
\nLoss of interest in activities that you used to enjoy?\n\n
\nFeeling distant or cut off from other people?\n\n
\nTrouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?\n\n
\nIrritable behavior, angry outbursts, or acting aggressively?\n\n
\nTaking too many risks or doing things that could cause you harm?\n\n
\nBeing "super alert" or watchful or on guard?\n\n
\nFeeling jumpy or easily startled?\n\n
\nHaving difficulty concentrating?\n\n
\nTrouble falling or staying asleep?\n\n
\nWhen you have to "wait in line," such as at a restaurant, a store,\nor the post office, do you:\nyou were restless?\n\n
\nFully satisfied with how these things are going?\n\n
\nRegularly involved in things that are important to you?\n\n
\nFunctioning your best in the most important things you do?\n\n
\nHow many days in the past 12 months have you used drugs other than alcohol?\n\n
\nHow many days in the past 12 months have you used drugs more than you meant to?\n\n
\nDEPRESSION: How would you describe your mood over the last two weeks? Do you remain reasonably cheerful or have you been very depressed or low-spirited recently? In the last two weeks, how often have you (own words) every day? All day?\n\n
\nHOPELESSNESS: How do you see the future for yourself? Can you see any future? Or has life seemed quite hopeless? Have you given up or does there still seem some reason for trying?\n\n
\nSELF-DEPRECIATION: What is your opinion of yourself compared to other people? Do you feel better, not as good, or about the same as others? Do you feel inferior or even worthless?\n\n
\nWhen you play games with young children about 10 years old,\nhow often do you purposely let them win?\n\n
\nGUILTY IDEAS OF REFERENCE: Do you have the feeling that you are being blamed for something or even wrongly accused? What about? (Do not include justifiable blame or accusation. Exclude delusions of guilt.)\n\n
\nPATHOLOGICAL GUILT: Do you tend to blame yourself for little things you may have done in the past? Do you think that you deserve to be so concerned about this?\n\n
\nMORNING DEPRESSION: When you have felt depressed over the last two weeks, have you noticed the depression being worse at any particular time of day?\n\n
\nEARLY WAKENING: Do you wake earlier in the morning than is normal for you? How many times a week does this happen?\n\n
\nSUICIDE: Have you felt that life wasn't worth living? Did you ever feel like ending it all? What did you think you might do? Did you actually try?\n\n
\nOBSERVED DEPRESSION: Based on interviewer's observations during the entire interview. The question "Do you feel like crying?", used at appropriate points in the interview, may elicit information useful to this observation.\n\n
\nNatural disaster (for example, flood, hurricane, tornado, earthquake)\n\n
\nFire or explosion\n\n
\nTransportation accident (for example, car accident, boat accident, train wreck, plane crash)\n\n
\nSerious accident at work, home, or during recreational activity\n\n
\nDo most people consider you to be:\n\n
\nExposure to toxic substance (for example, dangerous chemicals, radiation)\n\n
\nPhysical assault (for example, being attacked, hit, slapped, kicked, beaten up)\n\n
\nAssault with a weapon (for example, being shot, stabbed, threatened with a knife, gun, bomb)\n\n
\nSexual assault (rape, attempted rape, made to perform any type of sexual act through force or threat of harm)\n\n
\nOther unwanted or uncomfortable sexual experience\n\n
\nCombat or exposure to a war-zone (in the military or as a civilian)\n\n
\nCaptivity (for example, being kidnapped, abducted, held hostage, prisoner of war)\n\n
\nLife-threatening illness or injury\n\n
\nSevere human suffering\n\n
\nSudden violent death (for example, homicide, suicide)\n\n
\nNowadays, do you consider yourself to be:\n\n
\nSudden accidental death\n\n
\nSerious injury, harm, or death you caused to someone else\n\n
\nAny other very stressful event or experience\n\n
\nThis questionnaire asks about experiences you may have had after a very stressful experience. Please indicate whether you had at least one experience as described below that is currently distressing (select all that apply).||Select one or more:\n\n
\nI blame myself.\n\n
\nI have lost faith in humanity.\n\n
\nPeople would hate me if they really knew me.\n\n
\nI have trouble seeing goodness in others.\n\n
\nPeople don't deserve second chances.\n\n
\nI am disgusted by what happened.\n\n
\nHow would your spouse (or closest friend) rate you?\n\n
\nI feel like I don't deserve a good life.\n\n
\nI keep myself from having success.\n\n
\nI no longer believe there is a higher power.\n\n
\nI lost trust in others.\n\n
\nI am angry all the time.\n\n
\nI am not the good person I thought I was.\n\n
\nI have lost pride in myself.\n\n
\nI cannot be honest with other people.\n\n
\nFor the following questions of the B-IPF assessment, reflect on how much this experience made it hard for you to function in each of the areas listed. You must answer OK to proceed.\n\n
\nI had trouble in my romantic relationship with my spouse or partner.\n\n
\nHow often during the last year have you failed to do what was normally\nexpected from you because of drinking?\n \n\n
\nHow would your spouse (or best friend) rate your general\nlevel of activity?\n\n
\nI had trouble in my relationship with my children.\n\n
\nI had trouble with my family relationships.\n\n
\nI had trouble with my friendships and socializing.\n\n
\nI had trouble at work.\n\n
\nI had trouble with my training and education.\n\n
\nI had trouble with day to day activities, such as doing household chores, running errands and managing my medical care.\n\n
\nconcentration problems, easily distracted \n\n
\nanxious, worrying\n\n
\nnervous, fidgety\n\n
\ninattentive, daydreaming\n\n
\nWould people who know you well agree that you take your\nwork too seriously?\n\n
\nhot- or short-tempered, low boiling point\n\n
\ntemper outbursts, tantrums\n\n
\ntrouble with stick-to-it-tiveness, not following through, failing to finish things started\n\n
\nstubborn, strong-willed \n\n
\nsad or blue, depressed, unhappy\n\n
\ndisobedient with parents, rebellious, sassy\n\n
\nlow opinion of myself\n\n
\nirritable\n\n
\nmoody, ups and downs\n\n
\nangry\n\n
\nWould people who know you well agree that you have less energy\nthan most people?\n\n
\nacting without thinking, impulsive\n\n
\ntendency to be immature\n\n
\nguilty feelings, regretful\n\n
\nlosing control of myself\n\n
\ntendency to be or act irrational\n\n
\nunpopular with other children, didn't keep friends for long, didn't get along with other children\n\n
\ntrouble seeing things from someone else's point of view\n\n
\ntrouble with authorities, trouble with school, visits to principal's office\n\n
\noverall a poor student, slow learner\n\n
\ntrouble with mathematics or numbers\n\n
\nWould people who know you well agree that you tend to get\nIrritated easily?\n\n
\nnot achieving up to potential\n\n
\nHow often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?\n\n
\nHow often do you have difficulty getting things in order when you have to do a task that requires organization?\n\n
\nHow often do you have problems remembering appointments or obligations?\n\n
\nWhen you have a task that requires a lot of thought, how often do you avoid or delay getting started?\n\n
\nHow often do you fidget or squirm with your hands or feet when you have to sit down for a long time?\n\n
\nHow often do you feel overly active and compelled to do things, like you were driven by a motor?\n\n
\nHow often do you make careless mistakes when you have to work on a boring or difficult project?\n\n
\nHow often do you have difficulty keeping your attention when you are doing boring or repetitive work?\n\n
\nHow often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?\n\n
\nWould people who know you well agree that you tend to do most\nthings in a hurry?\n\n
\nHow often do you misplace or have difficulty finding things at home or at work?\n\n
\nHow often are you distracted by activity or noise around you?\n\n
\nHow often do you leave your seat in meetings or other situations in which you are expected to remain seated?\n\n
\nHow often do you feel restless or fidgety?\n\n
\nHow often do you have difficulty unwinding and relaxing when you have time to yourself?\n\n
\nHow often do you find yourself talking too much when you are in social situations?\n\n
\nWhen you're in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?\n\n
\nHow often do you have difficulty waiting your turn in situations when turn taking is required?\n\n
\nHow often do you interrupt others when they are busy?\n\n
\nWould people who know you well agree that you enjoy\n"a contest" (competition) and try hard to win?\n\n
\nI have been unhappy because of my drinking or drug use.\n\n
\nBecause of my drinking or drug use, I have lost weight or not eaten properly.\n\n
\nI have failed to do what is expected of me because of my drinking or drug use.\n\n
\nWhen drinking or using drugs, my personality has changed for the worse.\n\n
\nI have taken foolish risks when I have been drinking or using drugs.\n\n
\nWhile drinking or using drugs, I have said harsh or cruel things to someone.\n\n
\nWhen drinking or using drugs, I have done impulsive things that I regretted later.\n\n
\nI have had money problems because of my drinking or drug use.\n\n
\nMy physical appearance has been harmed by my drinking or drug use.\n\n
\nMy family has been hurt by my drinking or drug use.\n\n
\nWould people who know you well agree that you get a lot of fun\nout of your life?\n\n
\nA friendship or close relationship has been damaged by my drinking or drug use.\n\n
\nI have lost interest in activities and hobbies because of my drinking or drug use.\n\n
\nMy drinking or drug use has gotten in the way of my growth as a person.\n\n
\nMy drinking or drug use has damaged my social life, popularity, or reputation.\n\n
\nI have spent too much or lost a lot of money\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nHow was your "temper" when you were younger?\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nHow is your "temper" nowadays?\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nWhen you are in the midst of studying and someone interrupts you,\nhow do you usually feel inside?\nare unnecessary\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nEver:\n\n
\nIn the past 30 days:\n\n
\nELEVATED MOOD\n\n
\nINCREASED MOTOR ACTIVITY ENERGY\n\n
\nSEXUAL INTEREST\n\n
\nSLEEP\n\n
\nHow often during the last year have you needed a first drink in the\nmorning to get yourself going after a heavy drinking session?\n \n\n
\nHow often are there deadlines in your courses? (if deadlines occur\nIrregularly, choose the closest answer)?\n\n
\nIRRITABILITY\n\n
\nSPEECH (Rate and Amount)\n\n
\nLANGUAGE - THOUGHT DISORDER\n\n
\nCONTENT\n\n
\nDISRUPTIVE - AGGRESSIVE BEHAVIOR\n\n
\nAPPEARANCE\n\n
\nINSIGHT\n\n
\nAlternating Trail Making. Correct Pattern: 1-A- 2- B- 3- C- 4- D- 5- E, without drawing any lines that cross. Any error that is not immediately self-corrected is scored incorrect.\n\n
\nCube-Visuoconstructional Skills. Correct: All must be present: three-dimensional, all lines are drawn, no line is added, lines are relatively parallel and their length is similar.\n\n
\nClock face must be a circle with only minor distortion acceptable (e.g., slight imperfection on closing the circle).\n\n
\nDo these deadlines:\nthings a great deal?\n\n
\nAll clock numbers must be present with no additional numbers; numbers must be in the correct order and placed in the approximate quadrants on the clock face; Roman numerals are acceptable; numbers can be placed outside the circle contour.\n\n
\nThere must be two hands jointly indicating the correct time; the hour hand must be clearly shorter than the minute hand; hands must be centered within the clock face with their junction close to the clock center.\n\n
\nLion\n\n
\nRhinoceros or rhino\n\n
\nCamel or dromedary\n\n
\nForward Digit Span.\n\n
\nBackward Digit Span. Correct response for the backwards trial is 7-4-2.\n\n
\nVigilance. Correct when there is zero to one errors (an error is a tap on a wrong letter or a failure to tap on letter A).\n\n
\nSerial 7 subtraction starting at 100. Continue for five responses.\n\n
\nSentence repetition. I only know that John is the one to help today.\n\n
\nDo you ever set deadlines or quotas for yourself in courses\nor other things?\n\n
\nSentence repetition. That cat always hid under the couch when dogs were in the room.\n\n
\nWords beginning with the letter F.\n\n
\nSimilarity between TRAIN - BICYCLE.\n\n
\nSimilarity between WATCH - RULER.\n\n
\nRecall FACE.\n\n
\nRecall VELVET.\n\n
\nRecall CHURCH\n\n
\nRecall DAISY.\n\n
\nRecall RED.\n\n
\nToday's date.\n\n
\nWhen you have to work against a deadline, is the quality\nof your work:\n\n
\nCurrent month\n\n
\nCurrent year\n\n
\nDay of the week\n\n
\nWhat place is this?\n\n
\nWhat city are we in?\n\n
\nYears of formal education:\n\n
\nAlternating Trail Making. Correct Pattern: 1-A- 2- B- 3- C- 4- D- 5- E, without drawing any lines that cross. Any error that is not immediately self-corrected is scored incorrect.\n\n
\nChair-Visuoconstructional Skills. Correct: All must be present: three-dimensional, all lines are drawn, no line is added, lines are relatively parallel and their length is similar.\n\n
\nClock face must be a circle with only minor distortion acceptable (e.g., slight imperfection on closing the circle).\n\n
\nAll clock numbers must be present with no additional numbers; numbers must be in the correct order and placed in the approximate quadrants on the clock face; Roman numerals are acceptable; numbers can be placed outside the circle contour.\n\n
\nIn school do you ever keep two projects moving forward\nat the same time by shifting back and forth rapidly from\none to the other?\n\n
\nThere must be two hands jointly indicating the correct time; the hour hand must be clearly shorter than the minute hand; hands must be centered within the clock face with their junction close to the clock center.\n\n
\nSnake or a type of snake like Boa or Cobra\n\n
\nElephant\n\n
\nCrocodile or alligator\n\n
\nForward Digit Span.\n\n
\nBackward Digit Span. Correct response for the backwards trial is 2-4-7.\n\n
\nVigilance. Correct when there is zero to one errors (an error is a tap on a wrong letter or a failure to tap on letter A).\n\n
\nSerial 7 subtraction starting at 70. Continue for five responses.\n\n
\nSentence repetition. The robber of the gray car was stopped by the police.\n\n
\nSentence repetition. The student went back to school without his books and pencils.\n\n
\nDo you maintain a regular study schedule during vacations such\nas thanksgiving, christmas, and easter?\n\n
\nWords beginning with the letter S.\n\n
\nSimilarity between BED - TABLE.\n\n
\nSimilarity between LETTER - TELEPHONE.\n\n
\nRecall HAND.\n\n
\nRecall NYLON\n\n
\nRecall PARK.\n\n
\nRecall CARROT.\n\n
\nRecall YELLOW.\n\n
\nToday's date.\n\n
\nCurrent month\n\n
\nHow often do you bring your work home with you at night or\nstudy materials related to your courses?\n\n
\nCurrent year\n\n
\nDay of the week\n\n
\nWhat place is this?\n\n
\nWhat city are we in?\n\n
\nYears of formal education:\n\n
\nAlternating Trail Making. Correct Pattern: 1-A- 2- B- 3- C- 4- D- 5- E, without drawing any lines that cross. Any error that is not immediately self-corrected is scored incorrect.\n\n
\nBed-Visuoconstructional Skills. Correct: All must be present: three-dimensional, all lines are drawn, no line is added, lines are relatively parallel and their length is similar.\n\n
\nClock face must be a circle with only minor distortion acceptable (e.g., slight imperfection on closing the circle).\n\n
\nAll clock numbers must be present with no additional numbers; numbers must be in the correct order and placed in the approximate quadrants on the clock face; Roman numerals are acceptable; numbers can be placed outside the circle contour.\n\n
\nThere must be two hands jointly indicating the correct time; the hour hand must be clearly shorter than the minute hand; hands must be centered within the clock face with their junction close to the clock center.\n\n
\nHow often do you go to the school when it is officially closed\n(such as nights or weekends)?\n\n
\nHorse, pony, mare or foal\n\n
\nTiger\n\n
\nDuck\n\n
\nForward Digit Span.\n\n
\nBackward Digit Span. Correct response for the backwards trial is 4-2-7.\n\n
\nVigilance. Correct when there is zero to one errors (an error is a tap on a wrong letter or a failure to tap on letter A).\n\n
\nSerial 7 subtraction starting at 60. Continue for five responses.\n\n
\nSentence repetition. The child walked his dog in the park after midnight.\n\n
\nSentence repetition. The artist finished his painting at the right moment for the exhibition.\n\n
\nWords beginning with the letter B.\n\n
\nWhen you find yourself getting tired while studying, do you\nusually:\nof the tiredness.\n\n
\nSimilarity between HAMMER - SCREWDRIVER.\n\n
\nSimilarity between MATCHES - LAMP.\n\n
\nRecall LEG.\n\n
\nRecall COTTON.\n\n
\nRecall SCHOOL.\n\n
\nRecall TOMATO.\n\n
\nRecall WHITE.\n\n
\nToday's date.\n\n
\nCurrent month\n\n
\nCurrent year\n\n
\nWhen you are in a group, do the other people tend to look to you\nto provide leadership?\n\n
\nDay of the week\n\n
\nWhat place is this?\n\n
\nWhat city are we in?\n\n
\nYears of formal education:\n\n
\nForward Digit Span.\n\n
\nBackward Digit Span. Correct response for the backwards trial is 7-4-2.\n\n
\nVigilance. Correct when there is zero to one errors (an error is a tap on a wrong letter or a failure to tap on letter A).\n\n
\nSerial 7 subtraction starting at 100. Continue for five responses\n\n
\nSentence repetition. I only know that John is the one to help today.\n\n
\nSentence repetition. That cat always hid under the couch when dogs were in the room.\n\n
\nHow often during the last year have you had a feeling of guilt or remorse\nafter drinking?\n \n\n
\nDo you make yourself written lists of "things to do" to help you\nremember what needs to be done?\n\n
\nWords beginning with the letter F.\n\n
\nSimilarity between TRAIN - BICYCLE.\n\n
\nSimilarity between WATCH - RULER.\n\n
\nRecall FACE.\n\n
\nRecall VELVET.\n\n
\nRecall CHURCH\n\n
\nRecall DAISY.\n\n
\nRecall RED.\n\n
\nToday's date.\n\n
\nCurrent month\n\n
\nCompared to the average student, in amount of effort put forth\nI give:\n\n
\nCurrent year\n\n
\nDay of the week\n\n
\nWhat place is this?\n\n
\nWhat city are we in?\n\n
\nYears of formal education:\n\n
\nSpeech\n\n
\nSalivation\n\n
\nSwallowing\n\n
\nHandwriting\n\n
\nVeteran with gastrostomy and >50% daily nutrition intake via G-tube\n\n
\nCompared to the average student, in sense of responsibility,\nI am:\n\n
\nCutting food and handling utensils (patients without gastrostomy)\n\n
\nCutting food and handling utensils (patients with gastrostomy)\n\n
\nDressing and hygiene\n\n
\nTurning in bed and adjusting bed clothes\n\n
\nWalking\n\n
\nClimbing stairs\n\n
\nDyspnea\n\n
\nOrthopnea\n\n
\nRespiratory insufficiency\n\n
\nI have experienced pain.\n\n
\nCompared to the average student, I find it necessary to hurry:\n\n
\nI have experienced fatigue.\n\n
\nI have experienced excessive saliva.\n\n
\nI have experienced problems with speaking.\n\n
\nI have experienced problems with my strength and ability to move.\n\n
\nI have experienced problems with sleep.\n\n
\nI have felt physically terrible.\n\n
\nThe world has been caring and responsive to my needs.\n\n
\nI have felt supported.\n\n
\nI have been depressed.\n\n
\nRelationships with those closest to me have been satisfying.\n\n
\nCompared to the average student, in being precise (careful\nabout detail), I am:\n\n
\nMy religion has been a source of strength or comfort to me.\n\n
\nI consider myself to have been religious or spiritual.\n\n
\nI have felt hopeless.\n\n
\nI have felt sad.\n\n
\nI have enjoyed the beauty of my surroundings.\n\n
\nMy desire for emotional intimacy has been strong.\n\n
\nI have shared emotional intimacy with others.\n\n
\nMy desire for physical intimacy has been strong.\n\n
\nI have shared physical intimacy with others.\n\n
\nMy painful experiences and memories make it difficult for me to live a life that I would value.\n\n
\nCompared to the average student, I approach life in general:\n\n
\nI'm afraid of my feelings.\n\n
\nI worry about not being able to control my worries and feelings.\n\n
\nMy painful memories prevent me from having a fulfilling life.\n\n
\nEmotions cause problems in my life.\n\n
\nIt seems like most people are handling their lives better than I am.\n\n
\nWorries get in the way of my success.\n\n
\nPlease assess your overall quality of life over the past week (7 days). Considering all parts of my life - physical, emotional, social, spiritual, and financial - over the past week, the quality of my life has been:\n\n
\nAge 65+\n\n
\nDiagnosis (3 or more co-existing)|\nIncludes only documented medical diagnoses\n\n
\nPrior history of falls within 3 months|\nAny unintentional change in position resulting in coming to rest on the ground or at a lower level\n\n
\nI want you to . . .\nallow me more freedom.\n\n
\nIncontinence|\nInability to make it to the bathroom or commode in timely manner|\nIncludes frequency, urgency, and/or nocturia.\n\n
\nVisual Impairment|\nIncludes but not limited to, macular degeneration, diabetic retinopathies, visual field loss, age\nrelated changes, decline in visual acuity, accommodation, glare tolerance, depth perception, and\nnight vision or not wearing prescribed glasses or having the correct prescription.\n\n
\nImpaired functional mobility|\nMay include patients who need help with IADLS or ADLS or have gait or transfer problems,\narthritis, pain, fear of falling, foot problems, impaired sensation, impaired coordination or improper\nuse of assistive devices.\n\n
\nEnvironmental hazards|\nMay include but not limited to, poor illumination, equipment tubing, inappropriate footwear, pets,\nhard to reach items, floor surfaces that are uneven or cluttered, or outdoor entry and exits.\n\n
\nPoly Pharmacy (4 or more prescriptions - any type)|\nAll PRESCRIPTIONS including prescriptions for OTC meds. Drugs highly associated with fall risk\ninclude but not limited to, sedatives, anti-depressants, tranquilizers, narcotics, antihypertensives,\ncardiac meds, corticosteroids, anti-anxiety drugs, anticholinergic drugs, and hypoglycemic drugs. \n\n
\nPain affecting level of function|\nPain often affects an individual's desire or ability to move or pain can be a factor in depression or\ncompliance with safety recommendations.\n\n
\nCognitive impairment|\nCould include patients with dementia, Alzheimer's or stroke patients or patients who are\nconfused, use poor judgment, have decreased comprehension, impulsivity, memory deficits.\nConsider patients ability to adhere to the plan of care.\n\n
\nFeeling dizzy\n\n
\nLoss of balance\n\n
\nPoor coordination, clumsy\n\n
\nI want you to . . .\ndisplay more affection for me.\n\n
\nHeadaches\n\n
\nNausea\n\n
\nVision problems, blurring, trouble seeing\n\n
\nSensitivity to light\n\n
\nHearing difficulty\n\n
\nSensitivity to noise\n\n
\nNumbness or tingling on parts of my body\n\n
\nChange in taste and/or smell\n\n
\nLoss of appetite or increased appetite\n\n
\nPoor concentration, can't pay attention, easily distracted\n\n
\nI want you to . . .\nhave more respect for my judgment.\n\n
\nForgetfulness, can't remember things\n\n
\nDifficulty making decisions\n\n
\nSlowed thinking, difficulty getting organized, can't finish things\n\n
\nFatigue, loss of energy, getting tired easily\n\n
\nDifficulty falling or staying asleep\n\n
\nFeeling anxious or tense\n\n
\nFeeling depressed or sad\n\n
\nIrritability, easily annoyed\n\n
\nPoor frustration tolerance, feeling easily overwhelmed by things\n\n
\nI want you to . . .\nfeel more attached to me.\n\n
\nHow often during the last year have you been unable to remember what\nhappened the night before because you had been drinking?\n \n\n
\nI want you to . . .\ntreat me in a warmer and friendlier manner.\n\n
\nI want you to . . .\nbe more interested in my activities.\n\n
\nI want you to . . .\ntake me out more.\n\n
\nI want you to . . .\nfeel more confident about my ability to think critically.\n\n
\nI want you to . . .\nallow me to make more decisions.\n\n
\nI want you to . . .\ndisplay more love for me.\n\n
\nI want you to . . .\nfeel more strongly that I am a significant aspect of your life.\n\n
\nI want you to . . .\nhave more respect for my ability to think for myself.\n\n
\nI want you to . . .\nshare more of your recreational time with me.\n\n
\nI want you to . . .\ntell me what to do less often.\n\n
\nHave you or someone else been injured as a result of your drinking?\n \n\n
\nI want you to . . .\nbe more interested in me.\n\n
\nI want you to . . .\nbe warmer and closer in your behavior toward me.\n\n
\nI want you to . . .\nfeel more strongly that I am an important member of your group.\n\n
\nI want you to . . .\nhave more confidence in my ability to learn things.\n\n
\nI want you to . . .\nspend more time with me.\n\n
\nI want you to . . .\ngive me more freedom to choose my own friends.\n\n
\nI want you to . . .\nbe more interested in the things I am interested in.\n\n
\nI want you to . . .\nspend more time alone with me.\n\n
\nI want you to . . .\nput fewer limits on what I can do.\n\n
\nI want you to . . .\ngive me more praise for my accomplishments.\n\n
\nHas a relative or friend, or a doctor or other health worker been\nconcerned about your drinking or suggested that you cut down?\n \n\n
\nI want you to . . .\nbe more confident that I will succeed in life.\n\n
\nI want you to . . .\ngive me more attention.\n\n
\nI want you to . . .\nfeel more love for me.\n\n
\nI want you to . . .\nbe more interested in being at home with me.\n\n
\nI want you to . . .\nhave more confidence in my ability to take care of myself.\n\n
\nI want you to . . .\nallow me to think more for myself.\n\n
\nI want you to . . .\nfeel closer to me as a person.\n\n
\nI want you to . . .\nfeel more strongly that I am a significant person.\n\n
\nI want you to . . .\nhave more respect for my ability to solve problems.\n\n
\nI want you to . . .\ntake me more on trips.\n\n
\nDoes drinking help you to feel more important?\n \n \n\n
\nI want you to . . .\ncriticize me less for my conduct and manners.\n\n
\nI want you to . . .\nfeel more strongly that I am an important person.\n\n
\nI want you to . . .\nfeel more confident about my ability to succeed at difficult tasks.\n\n
\nI want you to . . .\nspend more of your free time with me.\n\n
\nI want you to . . .\nsupervise my activities less.\n\n
\nI want you to . . .\nfeel more affection for me.\n\n
\nI want you to . . .\nbe more confident that I can be trusted with responsibilities.\n\n
\nI want you to . . .\nspend more time showing me how to do things.\n\n
\nI want you to . . .\nInsist less on respect from me.\n\n
\nI want you to . . .\nfeel more warmth for me.\n\n