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Have you been bothered by unpleasant thoughts or images entering your mind:
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Yes/
No
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Severity:
Mild/Serious
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*concerns with contamination (dirt, germs chemicals, radiation)?
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*preoccupation with keeping objects (clothing, tools) in perfect order?
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*images of death or other horrible events?
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*personally unacceptable religious or sexual thoughts?
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Have you worried a lot about terrible things happening, such as:
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*fire, burglary, or flooding the house?
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*accidentally hitting a pedestrian with your car or letting it roll down the hill?
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*spreading an illness (giving someone AIDS)?
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*losing something valuable?
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*harm coming to a loved one because you weren't careful enough?
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Have you worried about acting on unwanted, senseless urges or impulses as:
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*physically harming a loved one; pushing a stranger down; or poisoning a guest?
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Have you felt driven to perform certain acts over and over again, such as:
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*excessive or ritualized washing, cleaning, or grooming?
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*checking light switches, water faucets, the stove, door locks, or brake?
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*counting or arranging, evening-up behaviors (making sure socks are the same height?)
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*collecting useless objects or inspecting the garbage before it is thrown out?
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*repeating routine actions a certain number of times or until it feels "just right".
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*need to touch objects or people?
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*unnecessary re-reading or re-writing; re-opening envelopes before mailing?
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*examining your body for signs of illness?
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*avoiding colors, numbers, or names that are associated with something feared?
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*needing to confess or repeatedly ask for assurance that you acted correctly?
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Have you had an extremely upsetting event in your life, such as childhood sexual abuse, rape, severe accident, witnessing a violent act? Only if you HAVE, do you...
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Y/N
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Severity
M/Mod/S
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have frequent, uncontrolled, and distressing recall of the event?
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have frequent distressing dreams of the event?
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act or feel as if the event were happening again?
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have intense psychological or physical reactions to things that are like the trauma?
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make attempts to avoid thoughts feelings, or conversations associated with the trauma?
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avoid activities, places or people that cause you to remember the event?
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have an inability to recall an important part of the event?
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have a general lack of interest, difficulty feeling emotions, or a general sense of foreboding?
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have difficulty sleeping, irritability, difficulty concentrating, startle response?
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As a PATTERN of behavior back to AT LEAST age of 20:
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Y/N
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Severity
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Have you made frantic efforts to avoid real or imagined abandonment?
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Have you had unstable and intense relationships (with partners quickly moving from great to jerks, etc.)?
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Do you have very unstable self-image or sense of self ?
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Do you tend to make quick self-damaging judgments about spending, sex, substances, binge eating?
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Do you have recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior?
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Are you subject to extreme irritability or anxiety usually lasting a few hours and only rarely more than a few days?
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Do you have longstanding feelings of emptiness?
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Do you have short episodes of stress-related paranoia (unbased fears) or being severely "out of touch" with reality?
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