Adult Self-Rated Cross Cutting Symptom Measure (Level 1)

Assessment 1 of 27

Form Instructions & Things to Know

How to fill this form:
  • Read each question carefully before selecting an answer.
  • Select the most accurate option based on your observations.
  • Do not skip questions; every response helps in the assessment.
Things to know:
10-15 Mins

Estimated completion time.

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Note: This is a screening and assessment tool, not clinical (medical).

First, please provide your contact information.

Information about the individual being assessed.

1. During the past TWO (2) WEEKS, how much (or how often) have you been bothered by having little interest or pleasure in doing things?
2. During the past TWO (2) WEEKS, how much (or how often) have you been feeling down, depressed, or hopeless?
3. During the past TWO (2) WEEKS, how much (or how often) have you been feeling more irritated, grouchy, or angry than usual?
4. During the past TWO (2) WEEKS, how much (or how often) have you been sleeping less than usual, but still have a lot of energy?
5. During the past TWO (2) WEEKS, how much (or how often) have you been starting lots more projects than usual or doing more risky things than usual? usual?
6. During the past TWO (2) WEEKS, how much (or how often) have you been feeling nervous, anxious, frightened, worried, or on edge?
7. During the past TWO (2) WEEKS, how much (or how often) have you been feeling panic or being frightened?
8. During the past TWO (2) WEEKS, how much (or how often) have you been avoiding situations that make you anxious?
9. During the past TWO (2) WEEKS, how much (or how often) have you experience unexplained aches and pains (e.g., head, back, joints, abdomen, legs)?
10. During the past TWO (2) WEEKS, how much (or how often) have you been feeling that your illnesses are not being taken seriously enough?
11. During the past TWO (2) WEEKS, how much (or how often) have you thoughts of actually hurting yourself?
12. During the past TWO (2) WEEKS, how much (or how often) have you been hearing things other people couldn’t hear, such as voices even when no one was around? one was around?
13. During the past TWO (2) WEEKS, how much (or how often) have you been feeling that someone could hear your thoughts, or that you could hear what another person was thinking? what another person was thinking?
14. During the past TWO (2) WEEKS, how much (or how often) have you had problems with sleep that affected your sleep quality over all?
15. During the past TWO (2) WEEKS, how much (or how often) have you had problems with memory (e.g., learning new information) or with location (e.g., finding your way home)?
16. During the past TWO (2) WEEKS, how much (or how often) have you had unpleasant thoughts, urges, or images that repeatedly enter your mind?
17. During the past TWO (2) WEEKS, how much (or how often) have you been feeling driven to perform certain behaviors or mental acts over and over again?
18. During the past TWO (2) WEEKS, how much (or how often) have you been feeling detached or distant from yourself, your body, your physical surroundings, or your memories? surroundings, or your memories?
19. During the past TWO (2) WEEKS, how much (or how often) have you not knowing who you really are or what you want out of life?
20. During the past TWO (2) WEEKS, how much (or how often) have you not feeling close to other people or enjoying your relationships with them?
21. During the past TWO (2) WEEKS, how much (or how often) have you been drinking at least 4 drinks of any kind of alcohol in a single day?
22. During the past TWO (2) WEEKS, how much (or how often) have you been smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco?
23. During the past TWO (2) WEEKS, how much (or how often) have you been smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco?
24. During the past TWO (2) WEEKS, how much (or how often) have you been using any of the following medicines ON YOUR OWN, that is, without a doctor’s prescription, in greater amounts or longer than prescribed [e.g., painkillers (like Vicodin), stimulants (like Ritalin or Adderall), sedatives or tranquilizers (like sleeping pills or Valium), or drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)]?