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

Clinician:*

Please select the clinician from the card given to you by the front desk:

Client Name*

First NameLast Name

Age*

Sex*

MaleFemale

Today's Date

Date

If this questionnaire is completed by an informant, what is your Name?

First NameLast Name

What is your relationship with the individual?

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

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.

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

Domain I.

	0 -None Not at all	1 - Slight Less than a day or two	2 - Mild Several days	3 - Moderate More than half of the days	4 - Severe Nearly every day
1. Little interest or pleasure in doing things?
2. Feeling down, depressed, or hopeless?

Highest Score within Domain I.*

Domain II.

	0 -None Not at all	1 - Slight Less than a day or two	2 - Mild Several days	3 - Moderate More than half of the days	4 - Severe Nearly every day
3. Feeling more irritated, grouchy, or angry than usual?

Highest Score within Domain II.*

Domain III.

	0 -None Not at all	1 - Slight Less than a day or two	2 - Mild Several days	3 - Moderate More than half of the days	4 - Severe Nearly every day
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?

Highest Score within Domain III.*

Domain IV.

	0 -None Not at all	1 - Slight Less than a day or two	2 - Mild Several days	3 - Moderate More than half of the days	4 - Severe Nearly every day
6. Feeling nervous, anxious, frightened, worried, or on edge?
7. Feeling panic or being frightened?
8. Avoiding situations that make you anxious?

Highest Score within Domain IV.*

Domain V.

	0 -None Not at all	1 - Slight Less than a day or two	2 - Mild Several days	3 - Moderate More than half of the days	4 - Severe Nearly every day
9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)?
10. Feeling that your illnesses are not being taken seriously enough?

Highest Score within Domain V.*

Domain VI.

	0 -None Not at all	1 - Slight Less than a day or two	2 - Mild Several days	3 - Moderate More than half of the days	4 - Severe Nearly every day
11. Thoughts of actually hurting yourself?

Highest Score within Domain VI.*

Domain VII.

	0 -None Not at all	1 - Slight Less than a day or two	2 - Mild Several days	3 - Moderate More than half of the days	4 - Severe Nearly every day
12. Hearing things other people couldn’t hear, such as voices even when no one was around?
13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?

Highest Score within Domain VII.*

Calculation

Domain VIII.

	0 -None Not at all	1 - Slight Less than a day or two	2 - Mild Several days	3 - Moderate More than half of the days	4 - Severe Nearly every day
14. Problems with sleep that affected your sleep quality over all?

Highest Score within Domain VIII.*

Domain IX.

	0 -None Not at all	1 - Slight Less than a day or two	2 - Mild Several days	3 - Moderate More than half of the days	4 - Severe Nearly every day
15. Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)?

Highest Score within Domain IX.*

Domain X.

	0 -None Not at all	1 - Slight Less than a day or two	2 - Mild Several days	3 - Moderate More than half of the days	4 - Severe Nearly every day
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?

Highest Score within Domain X.*

Domain XI.

	0 -None Not at all	1 - Slight Less than a day or two	2 - Mild Several days	3 - Moderate More than half of the days	4 - Severe Nearly every day
18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?

Highest Score within Domain XI.*

Domain XII.

	0 -None Not at all	1 - Slight Less than a day or two	2 - Mild Several days	3 - Moderate More than half of the days	4 - Severe Nearly every day
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?

Highest Score within Domain XII.*

Domain XIII.

	0 -None Not at all	1 - Slight Less than a day or two	2 - Mild Several days	3 - Moderate More than half of the days	4 - Severe Nearly every day
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)]?

Highest Score within Domain XIII.*

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