| RPT |
FOCI Symptom Severity Total Score: <-Part B->| |
Total Scores range from a minimum of 0 to a maximum of 20, with higher scores indicating greater symptom severity.| |
Questions and Answers| |
Part A:
Have you been bothered by unpleasant thoughts or images that repeatedly enter your mind, such as:| |
|
1. Concerns with contamination (dirt, germs, chemicals, radiation) or acquiring a serious illness such as AIDS?|
<*Answer_6814*>|
2. Overconcern with keeping objects (clothing, tools, etc) in perfect order or arranged exactly?|
<*Answer_6815*>|
3. Images of death or other horrible events?|
<*Answer_6816*>|
4. Personally unacceptable religious or sexual thoughts?|
<*Answer_6817*>| |
Have you worried a lot about terrible things happening, such as:| |
.| Florida Obsessive Compulsive Inventory (FOCI)|
5. Fire, burglary or flooding of the house?|
<*Answer_6818*>|
6. Accidentally hitting a pedestrian with your car or letting it roll down a hill?|
<*Answer_6819*>|
7. Spreading an illness (giving someone AIDS)?|
<*Answer_6820*>|
8. Losing something valuable?|
<*Answer_6821*>|
9. Harm coming to a loved one because you weren't careful enough?|
| Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN:
<*Answer_6822*>| |
Have you worried about acting on an unwanted and senseless urge or impulse, such as:| |
10. Physically 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?|
<*Answer_6823*>| |
Have you felt driven to perform certain acts over and over again, such as:| |
11. Excessive or ritualized washing, cleaning or grooming?|
<*Answer_6824*>|
<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | |
12. Checking light switches, water faucets, the stove, door locks or the emergency brake?|
<*Answer_6825*>|
13. Counting, arranging; evening-up behaviors (making sure socks are at same height)?|
<*Answer_6826*>|
14. Collecting useless objects or inspecting the garbage before it is thrown out?|
<*Answer_6827*>|
15. Repeating routine actions (in/out of chair, going through doorway, relighting cigarette) a certain number of times|
or until it feels just right?|
<*Answer_6828*>|
16. Needing to touch objects or people?|
<*Answer_6829*>|
17. Unnecessary rereading or rewriting; reopening envelopes before they are mailed?|
<*Answer_6830*>|
18. Examining your body for signs of illness?|
<*Answer_6831*>|
19. Avoiding 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?|
<*Answer_6832*>|
20. Needing to "confess" or repeatedly asking for reassurance that you said or did something correctly?|
<*Answer_6833*>| |
FOCI Symptom Checklist Total Score: <-Part A->| |
PART B: In the past month...|
1. On average, how much time is occupied by these thoughts or behaviors each day?|
<*Answer_6834*>|
2. How much distress do they cause you?|
<*Answer_6835*>|
3. How hard is it for you to control them?|
<*Answer_6836*>|
4. How much do they cause you to avoid doing anything, going anyplace or being with anyone?|
<*Answer_6837*>|
5. How much do they interfere with school work or your social or family life?|
<*Answer_6838*>| | |
Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities.
| $~
Total Scores range from a minimum of 0 to a maximum of 20, with higher scores indicating greater symptomatology.| |
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