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

Assessment 1 of 28

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 stomachaches, headaches, or other aches and pains?
2. During the past TWO (2) WEEKS, how much (or how often) have you worried about your health or about getting sick?
3. During the past TWO (2) WEEKS, how much (or how often) have you been bothered by not being able to fall asleep or stay asleep, or by waking up too early? up too early?
4. During the past TWO (2) WEEKS, how much (or how often) have you been bothered by not being able to pay attention when you were in class or doing homework or reading a book or playing a game?
5. During the past TWO (2) WEEKS, how much (or how often) have you had less fun doing things than you used to?
6. During the past TWO (2) WEEKS, how much (or how often) have you felt sad or depressed for several hours?
7. During the past TWO (2) WEEKS, how much (or how often) have you felt more irritated or easily annoyed than usual?
8. During the past TWO (2) WEEKS, how much (or how often) have you felt angry or lost your temper?
9. During the past TWO (2) WEEKS, how much (or how often) have you started lots more projects than usual or done more risky things than usual?
10. During the past TWO (2) WEEKS, how much (or how often) have you slept less than usual but still had a lot of energy?
11. During the past TWO (2) WEEKS, how much (or how often) have you felt nervous, anxious, or scared?
12. During the past TWO (2) WEEKS, how much (or how often) have you not been able to stop worrying?
13. During the past TWO (2) WEEKS, how much (or how often) have you not been able to do things you wanted to or should have done, because they made you feel nervous?
14. During the past TWO (2) WEEKS, how much (or how often) have you heard voices when there was no one there speaking about you or telling you what to do or saying bad things to you?
15. During the past TWO (2) WEEKS, how much (or how often) have you had visions when you were completely awake that is, seen something or someone that no one else could see?
16. During the past TWO (2) WEEKS, how much (or how often) have you had thoughts that kept coming into your mind that you would do something bad or that something bad would happen to you or to someone else?
17. During the past TWO (2) WEEKS, how much (or how often) have you felt the need to check on certain things over and over again, like whether a door was locked or whether the stove was turned off?
18. During the past TWO (2) WEEKS, how much (or how often) have you worried a lot about things you touched being dirty or having germs or being poisoned?
19. During the past TWO (2) WEEKS, how much (or how often) have you felt you had to do things in a certain way, like counting or saying special things, to keep something bad from happening?
20. In the past TWO (2) WEEKS, have you had an alcoholic beverage (beer, wine, liquor, etc.)?
21. In the past TWO (2) WEEKS, have you smoked a cigarette, a cigar, or pipe, or used snuff or chewing tobacco?
22. In the past TWO (2) WEEKS, have you used drugs like marijuana, cocaine or crack, club drugs (like Ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)?
23. In the past TWO (2) WEEKS, have you used any medicine without a doctor’s prescription to get high or change the way you feel (e.g., painkillers [like Vicodin], stimulants [like Ritalin or Adderall], sedatives or tranquilizers [like sleeping pills or Valium], or steroids)?
24. In the past TWO (2) WEEKS, have you, have you thought about killing yourself or committing suicide?
25. In the past TWO (2) WEEKS, have you EVER tried to kill yourself?