| RPT |
.| .| Cross-Cutting Symptom Assessment for DSM-5| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>|
or hopeless?| <*Answer_7217*>| 3. Feeling more irritated, grouchy, or angry than usual?| <*Answer_7218*>| 4. Sleeping less than usual, but still have a lot of energy?| <*Answer_7219*>| 5.
Starting lots more projects than usual or doing more risky things than usual?| <*Answer_7220*>| 6. Feeling nervous, anxious, frightened, worried, or on edge?| <*Answer_7221*>| 7. Feeling
panic or being frightened?| <*Answer_7222*>| 8. Avoiding situations that make you anxious?| <*Answer_7223*>| 9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)?|
<*Answer_7224*>| 10. Feeling that your illnesses are not being taken seriously enough?| <*Answer_7225*>| 11. Thoughts of actually hurting yourself?| <*Answer_7226*>| 12. Hearing things other
people couldnt hear, such as voices even when no one was around?| <*Answer_7227*>| 13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?|
<*Answer_7228*>| 14. Problems with sleep that affected your sleep quality over all?| <*Answer_7229*>| 15. Problems with memory (e.g., learning new information) or with location (e.g., finding way
home)?| <*Answer_7230*>| 16. Unpleasant thoughts, urges, or images that repeatedly enter your mind?| <*Answer_7231*>| 17. Feeling driven to perform certain behaviors or mental acts over and
over again?| <*Answer_7232*>| 18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?| <*Answer_7233*>| 19. Not knowing who you really are or
what you want out of life?| <*Answer_7234*>| 20. Not feeling close to other people or enjoying your relationships with them?| <*Answer_7235*>| 21. Drinking at least 4 drinks of any kind of
alcohol in a single day?| <*Answer_7236*>| 22. Smoking any cigarettes, a cigar, or pipe or using snuff or chewing tobacco?| <*Answer_7237*>| 23. Using any of the following medicines ON YOUR
DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | |Items/domains with a rating of MILD OR GREATER (or SLIGHT OR GREATER for items 21-23/Substance Use domain, 11/suicidal ideation
OWN, that is, without a doctors prescription, in greater amounts or longer than prescribed: painkillers (like Vicodin), stimulants (like Ritalin or Adderall), 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 glue), or meth (like speed)? |
<*Answer_7238*>| | | Copyright (c) 2013 American Psychiatric Association. All Rights Reserved. This material can be reproduced without permission by researchers and by clinicians for use with their
patients.| | 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 and procedures.| $~
and 12-13/psychosis )indicate the need for additional assessment.| | | Domain Results | | Domain Screening Results| |
I. Depression...................................<*Answer_7771*>| II. Anger........................................<*Answer_7772*>| III. Mania........................................<*Answer_7773*>|
IV. Anxiety......................................<*Answer_7774*>| V. Somatic Symptoms.............................<*Answer_7775*>| VI. Suicidal Ideation............................<*Answer_7776*>|
VII. Psychosis....................................<*Answer_7777*>| VIII. Sleep Problems...............................<*Answer_7778*>| IX. Memory.......................................<*Answer_7779*>|
X. Repetitive Thoughts and Behaviors............<*Answer_7780*>| XI. Dissociation.................................<*Answer_7781*>|
XII. Personality Functioning......................<*Answer_7782*>| XIII. Substance Use................................<*Answer_7783*>|
| Questions and Answers| | 1. Little interest or pleasure in doing things?| <*Answer_7216*>| 2. Feeling down, depressed,
|
