DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Child Age 11–17

Been bothered by stomachaches, headaches, or other aches and pains?

None – Not at allSlight – Rare, less than a day or twoMild – Several daysModerate – More than half the daysSevere – Nearly every day

Worried about your health or about getting sick?

None – Not at allSlight – Rare, less than a day or twoMild – Several daysModerate – More than half the daysSevere – Nearly every day

Been bothered by not being able to fall asleep or stay asleep, or by waking up too early?

None – Not at allSlight – Rare, less than a day or twoMild – Several daysModerate – More than half the daysSevere – Nearly every day

Been bothered by not being able to pay attention when you were in class or doing homework or reading a book or playing a game?

None – Not at allSlight – Rare, less than a day or twoMild – Several daysModerate – More than half the daysSevere – Nearly every day

Had less fun doing things than you used to?

None – Not at allSlight – Rare, less than a day or twoMild – Several daysModerate – More than half the daysSevere – Nearly every day

Felt sad or depressed for several hours?

None – Not at allSlight – Rare, less than a day or twoMild – Several daysModerate – More than half the daysSevere – Nearly every day

Felt more irritated or easily annoyed than usual?

None – Not at allSlight – Rare, less than a day or twoMild – Several daysModerate – More than half the daysSevere – Nearly every day

Felt angry or lost your temper?

None – Not at allSlight – Rare, less than a day or twoMild – Several daysModerate – More than half the daysSevere – Nearly every day

Started lots more projects than usual or done more risky things than usual?

None – Not at allSlight – Rare, less than a day or twoMild – Several daysModerate – More than half the daysSevere – Nearly every day

Slept less than usual but still had a lot of energy?

None – Not at allSlight – Rare, less than a day or twoMild – Several daysModerate – More than half the daysSevere – Nearly every day

Felt nervous, anxious, or scared?

None – Not at allSlight – Rare, less than a day or twoMild – Several daysModerate – More than half the daysSevere – Nearly every day

Not been able to stop worrying?

None – Not at allSlight – Rare, less than a day or twoMild – Several daysModerate – More than half the daysSevere – Nearly every day

Not been able to do things you wanted to or should have done, because they made you feel nervous?

None – Not at allSlight – Rare, less than a day or twoMild – Several daysModerate – More than half the daysSevere – Nearly every day

Heard voices—when there was no one there—speaking about you or telling you what to do or saying bad things to you?

None – Not at allSlight – Rare, less than a day or twoMild – Several daysModerate – More than half the daysSevere – Nearly every day

Had visions when you were completely awake—that is, seen something or someone that no one else could see?

None – Not at allSlight – Rare, less than a day or twoMild – Several daysModerate – More than half the daysSevere – Nearly every day

Had thoughts that kept coming into your mind that you would do something bad or that something bad would happen to you or to someone else?

None – Not at allSlight – Rare, less than a day or twoMild – Several daysModerate – More than half the daysSevere – Nearly every day

Felt the need to check on certain things over and over again, like whether a door was locked or whether the stove was turned off?

None – Not at allSlight – Rare, less than a day or twoMild – Several daysModerate – More than half the daysSevere – Nearly every day

Worried a lot about things you touched being dirty or having germs or being poisoned?

None – Not at allSlight – Rare, less than a day or twoMild – Several daysModerate – More than half the daysSevere – Nearly every day

Felt you had to do things in a certain way, like counting or saying special things, to keep something bad from happening?

None – Not at allSlight – Rare, less than a day or twoMild – Several daysModerate – More than half the daysSevere – Nearly every day

In the past TWO (2) WEEKS, have you had an alcoholic beverage (beer, wine, liquor, etc.)?

YesNo

In the past TWO (2) WEEKS, have you smoked a cigarette, a cigar, or pipe, or used snuff or chewing tobacco?

YesNo

In the past TWO (2) WEEKS, have you used drugs like marijuana, cocaine or crack, club drugs (like Ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)?

YesNo

In the past TWO (2) WEEKS, have you used any medicine without a doctor’s prescription to get high or change the way you feel (e.g., painkillers [like Vicodin], stimulants [like Ritalin or Adderall], sedatives or tranquilizers [like sleeping pills or Valium], or steroids)?

YesNo

In the last 2 weeks, have you thought about killing yourself or committing suicide?

YesNo

Have you EVER tried to kill yourself?

YesNo

DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Child Age 11–17

DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Child Age 11–17

hey December 15, 2020

Quiz Summary

Information

Results

Results

Categories

1. Question

2. Question

3. Question

4. Question

5. Question

6. Question

7. Question

8. Question

9. Question

10. Question

11. Question

12. Question

13. Question

14. Question

15. Question

16. Question

17. Question

18. Question

19. Question

20. Question

21. Question

22. Question

23. Question

24. Question

25. Question