Cross-Cutting Symptom Measure (Adult)

1. PATIENT INFORMATION

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The questions below ask about things that might have bothered you. For each question, check the box next to the number that best describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS.

1.Little interest or pleasure in doing things? 🛈
2.Feeling down, depressed, 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 more projects than usual or doing more risky things than usual? 🛈
6.Feeling nervous, anxious, frightened, worried? 🛈
7.Feeling panic or being frightened? 🛈
8.Avoiding situations that make you anxious? 🛈
9.Unexplained aches and pains (e.g. head, back)? 🛈
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 around? 🛈
13.Feeling someone could hear your thoughts, or that you could hear what another person’s? 🛈
14.Problems with sleep that affected your overall sleep quality? 🛈
15.Problems with memory (e.g., learning new info) or with location (e.g., finding your way home)? 🛈
16.Unpleasant thoughts, urges, or images 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 alcohol on a single day? 🛈
22.Smoking any cigarettes, a cigar, pipe, or chewing tobacco? 🛈
23.Using any of the following ON YOUR OWN, without a doctor’s prescription [e.g. painkillers, stimulants, sedatives or tranquilizers, or drugs like marijuana, club drugs, cocaine, inhalants, or methamphetamine 🛈