Your form has been sent, the below rating scale is OPTIONAL. Thanks for taking time to complete.  

DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure - Adult

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) W EEKS.

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

None

Not at all=0

Slight

Rare, less

than a day

or two=1

Mild

Several

days =2

Moderate

More than

half the

days=3

Severe

Nearly

every

day=4

1. Little in terest  or  pleasure in d oing t hings?

2. Feeling  down, d epressed, or  hopeless?

3. Feeling  more irritated, grouchy, or  angry than usual?

4. Sleeping less than usual, but  still have a lot  of energy?

5. Starting lots more projects than usual  or doing more risky things than usual?

6. Feeling nervous, anxious, frightened, worried, or on edge?

7. Feeling  panic or being  frightened?

8. Avoiding situations that make you anxious?

9. Unexplained aches and pains (e.g head, back, joints, abdomen, legs)?

10. Feeling  that your  illnesses are not  being taken seriously enough?

11. Thoughts of actually hurting yourself?

12. Hearing things other  people couldn’t  hear, such as voices even when no one was a round?

13. Feeling  that someone could hear your  thoughts, or that you could hear what another  person was thinking?

14. Problems with sleep that affected  your  sleep quality over  all?

15. Problems with memory ( e.g., learning new information) or  with location (e.g., finding your way home)?

16. Unpleasant  thoughts, urges, or images that repeatedly enter your mind?

17. Feeling  driven to perform certain behaviors or mental acts over and over again?

18. Feeling  detached or distant  from yourself, your body, your physical surroundings, or  your memories?

19. Not  knowing who you really are or  what you want  out  of life?

20. Not  feeling  close to other  people or  enjoying your  relationships with them?

21. Drinking at least 4 drinks of any kind of alcohol in a single day?

22. Smoking any cigarettes, a cigar, or pipe, or using snuff or  chewing tobacco?

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)]?

Thanks for submitting!