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DSM-5 Self-Rated Cross-Cutting Symptom Measure—Adult

Name: Age: Date:

If this questionnaire is completed by an informant, what is your relationship with the individual?

In a typical week, approximately how much time do you spend with the individual? hours/week

Instructions: The questions below ask about things that might have bothered you. For each question, select the number that best describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS.

During the past TWO (2) WEEKS, how much (or how often) have you been bothered by the following problems?

Little interest or pleasure in doing things?
0; None - Not at all

1; Slight - Rare, less than a day or two

2; Mild - Several days

3; Moderate - More than half the days

4; Severe - Nearly every day
Feeling down, depressed, or hopeless?
0; None – Not at all

1; Slight – Rare, less than a day or two

2; Mild – Several days

3; Moderate – More than half the days

4; Severe – Nearly every day
Feeling more irritated, grouchy, or angry than usual?
0; None – Not at all

1; Slight – Rare, less than a day or two

2; Mild – Several days

3; Moderate – More than half the days

4; Severe – Nearly every day
Sleeping less than usual, but still have a lot of energy?
0; None – Not at all

1; Slight – Rare, less than a day or two

2; Mild – Several days

3; Moderate – More than half the days

4; Severe – Nearly every day
Starting lots more projects than usual or doing more risky things than usual?
0; None – Not at all

1; Slight – Rare, less than a day or two

2; Mild – Several days

3; Moderate – More than half the days

4; Severe – Nearly every day
Feeling nervous, anxious, frightened, worried, or on edge?
0; None – Not at all

1; Slight – Rare, less than a day or two

2; Mild – Several days

3; Moderate – More than half the days

4; Severe – Nearly every day
Feeling panic or being frightened?
0; None – Not at all

1; Slight – Rare, less than a day or two

2; Mild – Several days

3; Moderate – More than half the days

4; Severe – Nearly every day
Avoiding situations that make you anxious?
0; None – Not at all

1; Slight – Rare, less than a day or two

2; Mild – Several days

3; Moderate – More than half the days

4; Severe – Nearly every day
Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)?
0; None – Not at all

1; Slight – Rare, less than a day or two

2; Mild – Several days

3; Moderate – More than half the days

4; Severe – Nearly every day
Feeling that your illnesses are not being taken seriously enough?
0; None – Not at all

1; Slight – Rare, less than a day or two

2; Mild – Several days

3; Moderate – More than half the days

4; Severe – Nearly every day
Thoughts of actually hurting yourself?
0; None – Not at all

1; Slight – Rare, less than a day or two

2; Mild – Several days

3; Moderate – More than half the days

4; Severe – Nearly every day
Hearing things other people couldn’t hear, such as voices even when no one was around?
0; None – Not at all

1; Slight – Rare, less than a day or two

2; Mild – Several days

3; Moderate – More than half the days

4; Severe – Nearly every day
Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?
0; None – Not at all

1; Slight – Rare, less than a day or two

2; Mild – Several days

3; Moderate – More than half the days

4; Severe – Nearly every day
Problems with sleep that affected your sleep quality over all?
0; None – Not at all

1; Slight – Rare, less than a day or two

2; Mild – Several days

3; Moderate – More than half the days

4; Severe – Nearly every day
Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)?
0; None – Not at all

1; Slight – Rare, less than a day or two

2; Mild – Several days

3; Moderate – More than half the days

4; Severe – Nearly every day
Unpleasant thoughts, urges, or images that repeatedly enter your mind?
0; None – Not at all

1; Slight – Rare, less than a day or two

2; Mild – Several days

3; Moderate – More than half the days

4; Severe – Nearly every day
Feeling driven to perform certain behaviors or mental acts over and over again?
0; None – Not at all

1; Slight – Rare, less than a day or two

2; Mild – Several days

3; Moderate – More than half the days

4; Severe – Nearly every day
Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?
0; None – Not at all

1; Slight – Rare, less than a day or two

2; Mild – Several days

3; Moderate – More than half the days

4; Severe – Nearly every day
Not knowing who you really are or what you want out of life?
0; None – Not at all

1; Slight – Rare, less than a day or two

2; Mild – Several days

3; Moderate – More than half the days

4; Severe – Nearly every day
Not feeling close to other people or enjoying your relationships with them?
0; None – Not at all

1; Slight – Rare, less than a day or two

2; Mild – Several days

3; Moderate – More than half the days

4; Severe – Nearly every day
Drinking at least 4 drinks of any kind of alcohol in a single day?
0; None – Not at all

1; Slight – Rare, less than a day or two

2; Mild – Several days

3; Moderate – More than half the days

4; Severe – Nearly every day
Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco?
0; None – Not at all

1; Slight – Rare, less than a day or two

2; Mild – Several days

3; Moderate – More than half the days

4; Severe – Nearly every day
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)]?
0; None – Not at all

1; Slight – Rare, less than a day or two

2; Mild – Several days

3; Moderate – More than half the days

4; Severe – Nearly every day

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June 10, 2020 10:48 am PDT

DSM-5 Self-Rated Cross-Cutting Symptom Measure—Adult Uploaded by Do Not Reply - donotreply@c-f-d.org IP 65.157.96.202

June 11, 2020 8:23 am PDT

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