DSM-5 Self – Rated Level 1 Cross – Cutting Symptom Measure – Adult 1 March 2024 By psycbotsogo.co.bw No Comments Welcome to your DSM-5 Self - Rated Level 1 Cross - Cutting Symptom Measure - Adult 1. Name: None 2. Age: None 3. Sex: Male Female None 4. Date: None 5. If this questionnaire is completed by an informant, what is your relationship with the individual? None 6. In a typical week, approximately how much time do you spend with the individual? ____________________ hours/week None 7. Instructions: The questions below ask about things that might have bothered you. For each question, circle the number that best describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS. None 8. During the past TWO (2) WEEKS, how much (or how often) have you been bothered by the following problems? None 9. 1. Little interest or pleasure in doing things? None Not at all Slight Rare, less than a day or two Mild Several days Moderate More than half the days Severe Nearly every day Highest Domain Score (clinician) None 10. 2. Feeling down, depressed, or hopeless? None Not at all Slight Rare, less than a day or two Mild Several days Moderate More than half the days Severe Nearly every day Highest Domain Score (clinician) None 11. 3. Feeling more irritated, grouchy, or angry than usual? None Not at all Slight Rare, less than a day or two Mild Several days Moderate More than half the days Severe Nearly every day Highest Domain Score (clinician) None 12. 4. Sleeping less than usual, but still have a lot of energy? None Not at all Slight Rare, less than a day or two Mild Several days Moderate More than half the days Severe Nearly every day Highest Domain Score (clinician) None 13. 5. Starting lots more projects than usual or doing more risky things than usual? None Not at all Slight Rare, less than a day or two Mild Several days Moderate More than half the days Severe Nearly every day Highest Domain Score (clinician) None 14. 6. Feeling nervous, anxious, frightened, worried, or on edge? None Not at all Slight Rare, less than a day or two Mild Several days Moderate More than half the days Severe Nearly every day Highest Domain Score (clinician) None 15. 7. Feeling panic or being frightened? None Not at all Slight Rare, less than a day or two Mild Several days Moderate more than half the days Severe Nearly every day Highest Domain score (clinician) None 16. 8. Avoiding situations that make you anxious? None Not at all Slight Rare, less than a day or two Mild Several days Moderate More than half the days Severe Nearly everyday Highest Domain Score None 17. 9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)? None Not at all Slight Rare, less than a day or two Mild Several days Moderate More than half the days Severe Nearly every day Highest Domain score (Clinician) None 18. 10. Feeling that your illnesses are not being taken seriously enough? None Not at all Slight Rare, less than a day or two Mild Several days Moderate More than half the days Severe Nearly every day Highest Domain Score (clinician) None 19. 11. Thoughts of actually hurting yourself? None Not at all Slight Rare, less than a day or two Mild Several days Moderate More than half the days Severe Nearly every day Highest Domain Score (clinician) None 20. 12. Hearing things other people couldn’t hear, such as voices even when no one was around? None Not at all Slight Rare, less than a day or two Mild Several days Moderate More than half the days Severe Nearly every day Highest Domain Score (clinician) None 21. 13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking? None Not at all Slight Rare, less than a day or two Mild Several days Moderate more than half the days Severe nearly every day Highest Domain Score (clinician) None 22. 14. Problems with sleep that affected your sleep quality over all? None Not at all Slight Rare less than a day or two Mild Several days Moderate More than half the days Severe Nearly every day Highest Domain Score (clinician) None 23. 15. Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)? None Not at all Slight Rare, less than a day or two Mild Several days Moderate More than half the days Severe Nearly every day Highest Domain Score (clinician) None 24. 16. Unpleasant thoughts, urges, or images that repeatedly enter your mind? None Not at all Slight Rare, less than a day or two Mild Several days Moderate More than half the days Severe Nearly every day Highest Domain Score (clinician) None 25. 17. Feeling driven to perform certain behaviors or mental acts over and over again? None Not at all Slight Rare, less than a day or two Mild Several days Moderate More than half the days Severe Nearly every day Highest Domain Score (clinician) None 26. 18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories? None Not at all Slight Rare, less than a day or two Mild Several days Moderate More than half the days Severe Nearly every day Highest Domain Score (clinician) None 27. 19. Not knowing who you really are or what you want out of life? None Not at all Slight Rare, less than a day or two Mild Several days Moderate More than half the days Severe Nearly every day Highest Domain Score (clinician) None 28. 20. Not feeling close to other people or enjoying your relationships with them? None Not at all Slight Rare, less than a day or two Mild Several days Moderate More than half the days Severe Nearly every day Highest Domain Score (clinician) None 29. 21. Drinking at least 4 drinks of any kind of alcohol in a single day? None Not at all Slight Rare, less than a day or two Mild Several days Moderate More than half the days Severe Nearly every day Highest Domain Score (clinician) None 30. 22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco? None Not at all Slight Rare, less than a day or two Mild Several days Moderate More than half the days Severe Nearly every day Highest Domain Score (clinician) None 31. 23. 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)]? None Not at all Slight Rare, Less than a day Mild Several days Moderate More than half the day Severe Nearly every day Highest Domain Score (clinician) None Time's upTime is Up!
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