In the past month, have you had the following thoughts, feelings, or experiences? Check “yes” or “no” for each item.
Do not include experiences that occur only while under the influence of alcohol, drugs or medications that were not prescribed to you.
If you answer “YES” to an item, also indicate how distressing that experience has been for you.
Please note, all fields are required.
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Question 1 of 42
1. Question
Do familiar surroundings sometimes seem strange, confusing, threatening or unreal to you?
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Question 2 of 42
2. Question
If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q1):
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Question 3 of 42
3. Question
Have you heard unusual sounds like banging, clicking, hissing, clapping or ringing in your ears?
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Question 4 of 42
4. Question
If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q2):
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Question 5 of 42
5. Question
Do things that you see appear different from the way they usually do?
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Question 6 of 42
6. Question
If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q3):
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Question 7 of 42
7. Question
Have you had experiences with telepathy, psychic forces, or fortune telling?
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Question 8 of 42
8. Question
If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q4):
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Question 9 of 42
9. Question
Have you felt that you are not in control of your own ideas or thoughts?
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Question 10 of 42
10. Question
If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q5):
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Question 11 of 42
11. Question
Do you have difficulty getting your point across, because you ramble or go off the track a lot when you talk?
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Question 12 of 42
12. Question
If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q6):
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Question 13 of 42
13. Question
Do you have strong feelings or beliefs about being unusually gifted or talented in some way?
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Question 14 of 42
14. Question
If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q7):
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Question 15 of 42
15. Question
Do you feel that other people are watching you or talking about you?
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Question 16 of 42
16. Question
If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q8):
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Question 17 of 42
17. Question
Do you sometimes get strange feelings on or just beneath your skin, like bugs crawling?
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Question 18 of 42
18. Question
If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q9):
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Question 19 of 42
19. Question
Do you sometimes feel suddenly distracted by distant sounds that you are not normally aware of?
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Question 20 of 42
20. Question
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Question 21 of 42
21. Question
Have you had the sense that some person or force is around you, although you couldn’t see anyone?
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Question 22 of 42
22. Question
If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q11):
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Question 23 of 42
23. Question
Do you worry at times that something may be wrong with your mind?
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Question 24 of 42
24. Question
If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q12):
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Question 25 of 42
25. Question
Have you ever felt that you don’t exist, the world does not exist, or that you are dead?
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Question 26 of 42
26. Question
If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q13):
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Question 27 of 42
27. Question
Have you been confused at times whether something you experienced was real or imaginary?
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Question 28 of 42
28. Question
If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q14):
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Question 29 of 42
29. Question
Do you hold beliefs that other people would find unusual or bizarre?
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Question 30 of 42
30. Question
If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q15):
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Question 31 of 42
31. Question
Do you feel that parts of your body have changed in some way, or that parts of your body are working differently?
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Question 32 of 42
32. Question
If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q16):
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Question 33 of 42
33. Question
Are your thoughts sometimes so strong that you can almost hear them?
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Question 34 of 42
34. Question
If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q17):
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Question 35 of 42
35. Question
Do you find yourself feeling mistrustful or suspicious of other people?
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Question 36 of 42
36. Question
If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q18):
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Question 37 of 42
37. Question
Have you seen unusual things like flashes, flames, blinding light, or geometric figures?
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Question 38 of 42
38. Question
If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q19):
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Question 39 of 42
39. Question
Have you seen things that other people can’t see or don’t seem to see?
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Question 40 of 42
40. Question
If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q20):
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Question 41 of 42
41. Question
Do people sometimes find it hard to understand what you are saying?
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Question 42 of 42
42. Question
If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q21):
CorrectIncorrect