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4.1 The Volatile Solvent Screening Inventory and Comprehensive Solvent Assessment Interview (Copyright by Matthew O. Howard, 2003) follow below along with the face sheet, cards, and standardized definitions employed for the interview.
SUBJECT CODE NUMBER:Neuropsychiatric Impairments In Adolescent Inhalant Users
Participant’s Name: ______
Date of Screen: ______
Interviewer’s Name: ______
Date of First Interview: ______
Interviewer’s Name: ______
Date of Second Interview: ______
Interviewer’s Name: ______
Date of Birth: ______
DCN/SSN: ______
Facility Name: ______
Date of Entry: ______
Expected Date of Discharge: ______
Service Coordinator: ______
This form will be kept in a locked file cabinet, separate from the interview instrument. Do not attach this form to the completed instrument.
EDITOR: / EDITORID / ID CODE: / IDEDIT DATE: / EDITDATE / INTERVIEWER: / INTID
DATE:
START TIME: / :
STOP TIME: / :
Volatile Solvent Screening Inventory
(Copyright 2003, Matthew O. Howard, PhD)
INTRODUCTION: Hi, my name is ______and I will be doing the interview with you. I want to thank you for your time and willingness to do this.The purpose of this interview is to help us find out about your thoughts, feelings, and past and current behaviors.
The interview will take about 60 to 90 minutes.
We will start by going over a description of what the interview will involve and what your rights are in this process. OK?
COMPLETE ASSENT OR CONSENT FORM
FACE SHEET
Section A: Demographics
A1. / RECORD SEX AS OBSERVED. / MALE / 1 /FEMALE / 2
A2. / How old are you? / years /
A3. / In which racial or ethnic group do you consider yourself?
[PROMPT ONLY IF THEY CAN’T THINK OF A GROUP] / AFRICAN AMERICAN / 1
WHITE / 2
LATINO/LATINA / 3
BIRACIAL (SPECIFY):
______/ 4
OTHER (SPECIFY):
______/ 7
A4. / What grade are you in now? [IF ON SUMMER VACATION OR NOT IN SCHOOL: What grade did you just complete?] / grade
A5. / Before coming into DYS custody, what type area did you live in? / Urban City / 1
Suburban Area near a City / 2
SmallTown / 3
Rural Or Country Area / 4
A6. / Does your family receive public assistance such as Section 8 housing, Food Stamps, TANF (welfare) payouts? / NO / 0
YES / 1
Section B: Time in/Time Remaining in Custody
B1. / How many months have you been in DYS custody? / monthsB2. / How many months from today until you will be released from DYS custody? / months /
B3. / How many months from today until you can leave the facility you are currently living in? / months /
B4. / Were you in a detention center immediately before you came to the current facility?
NO. [GO TO NEXT SECTION].0
YES…………….…………1
B5. / How long were you held at the DetentionCenter before you came to a DYS facility this time? /
weeks
Section C: Exclusion Criteria
ASK THE FOLLOWING QUESTIONS AND RECORD EITHER A NO OR YES RESPONSE FOR EACH. / No / Yes1. / Is English is your primary language? That is, the language you most often speak and are most comfortable using. / 0 / 1
2. / In your lifetime, have you ever had a head injury that caused you to blackout for more than 20 minutes? / 0 / 1
3. / Have you ever suffered from any of the following: /
a. Major illness or injury around the time of birth (e.g., measles, pneumonia, etc.) [IF RESPONDENT SAYS “YES,” RECORD SPECIFIC ILLNESS(ES) OR INJURY(IES)] ______ / 0 / 1 /
b. A brain infection, brain tumor, or brain disease such as epilepsy or meningitis [IF RESPONDENT SAYS “YES,” RECORD SPECIFIC ILLNESS(ES) OR INJURY(IES)] ______ / 0 / 1 /
c. Kidney disease(e.g., related to diabetes)
[IF RESPONDENT SAYS “YES,” RECORD SPECIFIC ILLNESS(ES) OR INJURY(IES)] ______ / 0 / 1 /
d. Hormonal disorders such as thyroid problems or diabetes [IF RESPONDENT SAYS “YES,” RECORD SPECIFIC ILLNESS(ES) OR INJURY(IES)] ______ / 0 / 1 /
e. Blood disorder such as anemia or leukemia [IF RESPONDENT SAYS “YES,” RECORD SPECIFIC ILLNESS(ES) OR INJURY(IES)] ______ / 0 / 1 /
4. / What medications are you currently taking that were prescribed to you by a doctor or psychiatrist? ______/ /
/ No / Yes
5. / Has a doctor or psychiatrist ever diagnosed you with a mental illness? What did the doctor say was your diagnosis? [RECORD SPECIFIC DIAGNOSIS OR CONDITION MENTIONED BY YOUTH]
/ 0 / 1 /
6. / Have you ever heard voices of people who were not actually there? / 0 / 1 /
Section D: Inhalant Use Screening Measure
Now I’m going to ask you about some things youth commonly inhale or huff through their nose or mouth in order to get high. [READ THE NAME OF EACH INHALANT LISTED BELOW TO THE YOUTH AND CIRCLE EITHER NO (0) OR YES (1) FOR EACH INHALANT IN COLUMN A. RECORD WHETHER THE YOUTH ACTUALLY GOT HIGH IN COLUMN B, THE NUMBER OF LIFETIME DAYS OF USE IN COLUMN C, THEN IN COLUMN D RECORD THE NUMBER OF DAYS OF USE FOR THE LAST YEAR PRIOR TO BEING IN CUSTODY.]A.FOR EACH INHALANT ASK: Have you ever inhaled/huffed [INHALANT] through your nose or mouth in an effort to get high?
IF 1 (YES) IS CIRCLED IN COL. A, ASK:
B. Did you actually get high?
C. How many days have you used [INHALANT] in your lifetime?
D. And on how many days did you use [INHALANT] in the 12 months before you were in custody?
E. How did you most often use [EACH CODED INHALANT]
1. Spray the substance directly into your mouth or nose = 1
2. Sniff or inhale from a plastic bag placed over your nose, mouth, or head = 2
3. Sniff or inhale from a cloth or clothing saturated with the substance and placed over your
nose, mouth, or head = 3
4. Sniff or inhale from a container (such as a jar or bottle) or balloon filled with gas = 4
5. Other (please record subject’s response) = 5
A. / B. / C. / D. / E.
Have you ever used … / Did you actually get high? / Days of use over your lifetime / Days of use in 12 months prior to custody / How did you most often use it?
Paint
/ No / Yes / No / Yes / / /D1. Paint thinner or turpentine / 0 / 1 / 0 / 1 / ______/ ______/ ______
D2. Spray paint / 0 / 1 / 0 / 1 / ______/ ______/ ______
D3. Liquid paint / 0 / 1 / 0 / 1 / ______/ ______/ ______
/ A. / B. / C. / D. / E.
Have you ever used … / Did you actually get high? / Days of use over your lifetime / Days of use in the 12 months prior to custody / How did you most often use it?
No / Yes / No / Yes / / /
D4. Paint remover or stripper / 0 / 1 / 0 / 1 / ______/ ______/ ______
D5. Any other paint-related product (specify:______) / 0 / 1 / 0 / 1 / ______/ ______/ ______
Glue
/ / / / /D6. Airplane or model glue / 0 / 1 / 0 / 1 / ______/ ______/ ______
D7. Rubber cement / 0 / 1 / 0 / 1 / ______/ ______/ ______
D8. Balsa wood cement / 0 / 1 / 0 / 1 / ______/ ______/ ______
D9. Other special cements or glues (e.g., superglue) (specify:
______) / 0 / 1 / 0 / 1 / ______/ ______/ ______
D10. Toluene (“Tulio”) / 0 / 1 / 0 / 1 / ______/ ______/ ______
Shoe Products
D11. Shoe shine or polish / 0 / 1 / 0 / 1 / ______/ ______/ ______Gases
D12. Propane / 0 / 1 / 0 / 1 / ______/ ______/ ______D13. Butane (e.g., cigarette/cigar lighter gas) / 0 / 1 / 0 / 1 / ______/ ______/ ______
D14. Freon (e.g., from air conditioner or other appliance) / 0 / 1 / 0 / 1 / ______/ ______/ ______
D15. Other refrigerant or coolant gases / 0 / 1 / 0 / 1 / ______/ ______/ ______
D16. “PAM” or other vegetable “nonstick” cooking spray / 0 / 1 / 0 / 1 / ______/ ______/ ______
/ A. / B. / C. / D. / E.
Have you ever used … / Did you actually get high? / Days of use over your lifetime / Days of use in the 12 months prior to custody / How did you most often use it?
No / Yes / No / Yes
Nitrites
D17. Amyl nitrite (“poppers” or “snappers”) / 0 / 1 / 0 / 1 / ______/ ______/ ______D18. Butyl nitrite (“Rush,” “Locker Room,” “Medusa,” “Bolt,” “ Bullet,” “Climax”) / 0 / 1 / 0 / 1 / ______/ ______/ ______
D19. Any other product with amyl or butyl nitrite (specify:______) / 0 / 1 / 0 / 1 / ______/ ______/ ______
Anesthetic Gases
D20. Nitrous oxide (“laughing gas”) (NOTE: not at the dentist and not helium) / 0 / 1 / 0 / 1 / ______/ ______/ ______D21.Whippets (Carbon Dioxide [CO2] canisters containing Nitrous Oxide – not whipping cream cans) / 0 / 1 / 0 / 1 / ______/ ______/ ______
D22. Gas from whipping cream cans / 0 / 1 / 0 / 1 / ______/ ______/ ______
D23. Ether / 0 / 1 / 0 / 1 / ______/ ______/ ______
D24. Any other product containing anesthetic gases (specify:______) / 0 / 1 / 0 / 1 / ______/ ______/ ______
Aerosols
D25. “Scotch Guard” or another fabric protector / 0 / 1 / 0 / 1 / ______/ ______/ ______
/ A. / B. / C. / D. / E.
Have you ever used … / Did you actually get high? / Days of use over your lifetime / Days of use in the 12 months prior to custody / How did you most often use it?
No / Yes / No / Yes
D26. Deodorant spray / 0 / 1 / 0 / 1 / ______/ ______/ ______
D27. Hair spray / 0 / 1 / 0 / 1 / ______/ ______/ ______
D28. Hair moose / 0 / 1 / 0 / 1 / ______/ ______/ ______
D29. Air freshener (e.g., “Glade”) / 0 / 1 / 0 / 1 / ______/ ______/ ______
D30. Spray for sunburns or other pain relief spray (Analgesic spray) / 0 / 1 / 0 / 1 / ______/ ______/ ______
D31. Insecticide spray or fly spray (e.g., Raid) / 0 / 1 / 0 / 1 / ______/ ______/ ______
D32. Gases from computer “duster” sprays / 0 / 1 / 0 / 1 / ______/ ______/ ______
D33. Any other aerosol use / 0 / 1 / 0 / 1 / ______/ ______/ ______
Cleaning Agents
D34. Dry cleaning fluid or other dry cleaning products / 0 / 1 / 0 / 1 / ______/ ______/ ______D35. Spot remover / 0 / 1 / 0 / 1 / ______/ ______/ ______
D36. Degreasing agents (e.g., “Easy Off Oven Cleaner”) / 0 / 1 / 0 / 1 / ______/ ______/ ______
D37. Glass cleaner (e.g., aerosol not pump action) / 0 / 1 / 0 / 1 / ______/ ______/ ______
D38. Plaster and gum remover / 0 / 1 / 0 / 1 / ______/ ______/ ______
D39. Any other cleaning agent (specify:______) / 0 / 1 / 0 / 1 / ______/ ______/ ______
/ A. / B. / C. / D. / E.
Have you ever used … / Did you actually get high? / Days of use over your lifetime / Days of use in the 12 months prior to custody / How did you most often use it?
Other Solvents and Gases
/ No / Yes / No / YesD40. Nail polish / 0 / 1 / 0 / 1 / ______/ ______/ ______
D41. Nail polish remover / 0 / 1 / 0 / 1 / ______/ ______/ ______
D42. Acetone / 0 / 1 / 0 / 1 / ______/ ______/ ______
D43. “White-out” or another correction fluid / 0 / 1 / 0 / 1 / ______/ ______/ ______
D44. Fire extinguisher gases / 0 / 1 / 0 / 1 / ______/ ______/ ______
D45. Cooking gases (from gas stove) / 0 / 1 / 0 / 1 / ______/ ______/ ______
D46. Octane booster (automobile product) / 0 / 1 / 0 / 1 / ______/ ______/ ______
Other Products
D47. Floor polisher / 0 / 1 / 0 / 1 / ______/ ______/ ______
D48. Car or other exhaust fumes / 0 / 1 / 0 / 1 / ______/ ______/ ______
D49. Kerosene / 0 / 1 / 0 / 1 / ______/ ______/ ______
D50. Gasoline / 0 / 1 / 0 / 1 / ______/ ______/ ______
D51. Lighter Fluid (for BBQ grill—not butane) / 0 / 1 / 0 / 1 / ______/ ______/ ______
D52. Antifreeze / 0 / 1 / 0 / 1 / ______/ ______/ ______
D53. Permanent markers / 0 / 1 / 0 / 1 / ______/ ______/ ______
D54. Dry erase markers / 0 / 1 / 0 / 1 / ______/ ______/ ______
/ A. / B. / C. / D. / E.
Have you ever used … / Did you actually get high? / Days of use over your lifetime / Days of use in the 12 months prior to custody / How did you most often use it?
No / Yes / No / Yes
D55. Paint pens / 0 / 1 / 0 / 1 / ______/ ______/ ______
D56. Carburetor cleaners (“Gum Out”) / 0 / 1 / 0 / 1 / ______/ ______/ ______
D57. “Brakeleen”/other automotive products / 0 / 1 / 0 / 1 / ______/ ______/ ______
D58. Apollo or another Stainless Steel Cleaner / 0 / 1 / 0 / 1 / ______/ ______/ ______
D59. Mothballs / 0 / 1 / 0 / 1 / ______/ ______/ ______
D60. Waxes / 0 / 1 / 0 / 1 / ______/ ______/ ______
D61. Gun cleaning solvents / 0 / 1 / 0 / 1 / ______/ ______/ ______
D62. Helium / 0 / 1 / 0 / 1 / ______/ ______/ ______
D63. Bottled Oxygen / 0 / 1 / 0 / 1 / ______/ ______/ ______
D64. Bleach / 0 / 1 / 0 / 1 / ______/ ______/ ______
D65. Hair dye / 0 / 1 / 0 / 1 / ______/ ______/ ______
/ Is there any other product or chemical that I have not asked you about that you inhaled through your nose or mouth in order to get high at some point in your life? Please specify.
B. / C. / D. / E.
Did you actually get high? / Days of use over your lifetime / Days of use in the 12 months prior to custody / How did you most often use it?
No / Yes
D66. Substance 1: ______/ 0 / 1 / ______/ ______/ ______
D67. Substance 2: ______/ 0 / 1 / ______/ ______/ ______
D68. Substance 3: ______/ 0 / 1 / ______/ ______/ ______
Section E: Nonprescription and Prescription Asthma Inhaler Abuse
E1. / Have you ever been diagnosed with asthma by a doctor or nurse? / NO...[SKIP TO E6]…0YES.……………….1
E2. / Were you ever prescribed an inhaler to help treat your asthma? / NO...[SKIP TO E6]…0
YES.……………….1
E3. / Did you ever use your asthma inhaler more than you were supposed to according to the doctor or pharmacist’s instructions? / NO...[SKIP TO E6]…0
YES.……………….1
E4. / On how many days in your lifetime did you use your asthma inhaler more than you were supposed to? / days
E5. / You said you were prescribed an asthma inhaler and used it more than the doctor or pharmacist recommended, did you do this to: / No / Yes
a. treat your own asthma symptoms / 0 / 1
b. see what it would feel like to try it / 0 / 1
c. try to get high / 0 / 1
E6. / Did you ever try to get an asthma inhaler by a method other than getting a doctor’s prescription for one? / NO...[SKIP TO E9]…0
YES.………………..1
E7. / Did you try to get an asthma inhaler without a prescription so that you could: / No / Yes
a. treat your own asthma symptoms / 0 / 1
b. see what it would feel like to try it / 0 / 1
c. use it to get high / 0 / 1
E8. / If you ever did obtain an asthma inhaler without a prescription, how did you obtain it? [RECORD RESPONDENT’S EXPLANATION]: ______
E9. / Did you ever use an asthma inhaler, even if you did not have a prescription from a doctor to use one? / NO…..[SKIP TO E12]…….0
YES.……………….……1
E10. / On how many days in your lifetime did you use an asthma inhaler without a doctor’s prescription? / days
E11. / You said you used an asthma inhaler without a doctor’s prescription, did you do this to: / No / Yes
a. treat your own asthma symptoms / 0 / 1
b. see what it would feel like to try it / 0 / 1
c. try to get high / 0 / 1
ASK E12 ONLY IF RESPONDENT HAS USED ASTHMA INHALER.
E12. / How often did you experience any of the following effects while using or immediately following use of the asthma inhaler? [SHOW YOUTH CARD E12, CIRCLE CORRESPONDING NUMBER]
Never / Rarely / Occasionally / Frequently / Always
Feel euphoric (feeling “high,” happy, carefree)? / 0 / 1 / 2 / 3 / 4
Feel more relaxed? / 0 / 1 / 2 / 3 / 4
Have blurred vision? / 0 / 1 / 2 / 3 / 4
See things that weren’t there? / 0 / 1 / 2 / 3 / 4
Hear things that weren’t there? / 0 / 1 / 2 / 3 / 4
Feel dizzy? / 0 / 1 / 2 / 3 / 4
Feel more talkative? / 0 / 1 / 2 / 3 / 4
Feel more sexually aroused? / 0 / 1 / 2 / 3 / 4
Feel more irritable? / 0 / 1 / 2 / 3 / 4
/ Never / Rarely / Occasionally / Frequently / Always
Feel more anxious? / 0 / 1 / 2 / 3 / 4
Feel panicky? / 0 / 1 / 2 / 3 / 4
Feel more aggressive? / 0 / 1 / 2 / 3 / 4
Feel more depressed? / 0 / 1 / 2 / 3 / 4
Feel more suicidal? / 0 / 1 / 2 / 3 / 4
Feel more nauseated? / 0 / 1 / 2 / 3 / 4
Have a headache? / 0 / 1 / 2 / 3 / 4
Have slurred speech? / 0 / 1 / 2 / 3 / 4
Feel more powerful or confident than normal? / 0 / 1 / 2 / 3 / 4
Feel more tired or fatigued than normal? / 0 / 1 / 2 / 3 / 4
Experience a burning sensation in your eyes or throat? / 0 / 1 / 2 / 3 / 4
Develop chestpain? / 0 / 1 / 2 / 3 / 4
Fear that you might be going crazy? / 0 / 1 / 2 / 3 / 4
Feel more confused? / 0 / 1 / 2 / 3 / 4
Have a rapid heartbeat? / 0 / 1 / 2 / 3 / 4
Find yourself unable to remember what you did? / 0 / 1 / 2 / 3 / 4
E13. / Did you experience any other unpleasant or scary physical or mental effects of nonprescribed asthma inhaler use? [IF YOUTH RESPONDS “YES,” PLEASE ASK YOUTH TO DESCRIBE THEIR EXPERIENCE, AND THEN RECORD THEM] ______
/
Section F: Drug Use
F1. / READ THE NAME OF EACH DRUG BELOW TO THE YOUTH AND CIRCLE EITHER NO (0) OR YES (1) FOR EACH DRUG IN COLUMN A. RECORD THE AGE AT FIRST USE IN COLUMN B. RECORD THE NUMBER OF LIFETIME OCCASIONS OF USE IN COLUMN C. IN COLUMN D, RECORD THE NUMBER OF OCCASIONS OF USE FOR THE LAST YEAR PRIOR TO BEING IN CUSTODY.A. / B. / C. / D.
FOR COLUMN A, ASK: Have you ever used[DRUG]? IF 1 (YES), ASK: How old were you the first time you used [DRUG]? RECORD AGE IN COLUMN B.THEN ASK: How many days have you used [DRUG] in your lifetime? RECORD IN COLUMN C. And on how many days did you use [DRUG] in the 12 months before you were in custody? RECORD IN COLUMN D. / Have you ever used … / Age at first use? / Number of days used in lifetime / Number of days used in the 12 months prior to custody
No / Yes
a. Heroin (Smack, Horse, Skag) / 0 / 1 / ___/___ / ______/ ______
b. Other opiates (e.g., methadone, opium, morphine, Oxycontin, Demerol, Vicodin) (not when prescribed) / 0 / 1 / ___/___ / ______/ ______
c. Cocaine or Crack Cocaine / 0 / 1 / ___/___ / ______/ ______
d. Barbiturates (Downers, Yellows, Reds, Blues, Soapers) / 0 / 1 / ___/___ / ______/ ______
e. Tranquilizers (e.g., Valium, Librium, Xanax, Serax) (not when prescribed) / 0 / 1 / ___/___ / ______/ ______
f. Speed (Meth, amphetamines, uppers, diet pills, Ritalin) (not when prescribed) / 0 / 1 / ___/___ / ______/ ______
g. Marijuana (Pot or Hash, THC, weed, blunts) / 0 / 1 / ___/___ / ______/ ______
h. Hallucinogens (“Acid,” LSD, mescaline, mushrooms, peyote) / 0 / 1 / ___/___ / ______/ ______
i. Malt Liquor (e.g., Old English 800, Mickey’s Malt, Colt 45) / 0 / 1 / ___/___ / ______/ ______
j. Other Alcohol (Beer, Wine, Liquor) / 0 / 1 / ___/___ / ______/ ______
/ A. / B. / C. / D.
Have you ever used … / Age at first use? / Number of days used in lifetime / Number of days used in the 12 months prior to custody
No / Yes
k. Ecstasy (i.e., E, Adam, or MDMA) / 0 / 1 / ___/___ / ______/ ______
l. GHB/GBL (gamma hydroxybutyrate, “grevious bodily harm”) / 0 / 1 / ___/___ / ______/ ______
m. Ketamine (Vitamin K, Special K) / 0 / 1 / ___/___ / ______/ ______
n. Cigarettes / 0 / 1 / ___/___ / ______/ ______
o. Cigars (tobacco, not marijuana) / 0 / 1 / ___/___ / ______/ ______
p. Oral Tobacco (Snuff/Chew) / 0 / 1 / ___/___ / ______/ ______
q. Cough Syrup (not when prescribed for medical reasons) / 0 / 1 / ___/___ / ______/ ______
r. Prescription Drugs without a prescription
(list drugs here:______) / 0 / 1 / ___/___ / ______/ ______
s. PCP / 0 / 1 / ___/___ / ______/ ______
t. Steroids / 0 / 1 / ___/___ / ______/ ______
/ TO YOUTH: “For the next eight questions please answer yes or no:” / No / Yes
F2. / Have you done anything you wish you hadn’t when you were drunk or high? / 0 / 1
F3. / Have your parents or friends thought you drink too much? / 0 / 1
F4. / Have you gotten in trouble when you have been high or have been drinking? [IF NO SKIP TO F6] / 0 / 1
F5. / Has the trouble been fighting? / 0 / 1
F6. / Have you used alcohol or drugs to help you feel better? / 0 / 1
F7. / Have you been drunk or high at school? / 0 / 1
F8. / Have you used alcohol and drugs at the same time? / 0 / 1
F9. / Have you been so drunk or high that you couldn’t remember what happened? / 0 / 1
/
Section G: Current/Lifetime Psychiatric Symptoms
G. / INTERVIEWER ASK YOUTH: Next I will read a list of thoughts and feelings. Tell me how much any of them have bothered or disturbed you over the last 7 days, including today. [SHOW YOUTH CARD G, RECORD EACH RESPONSE]Not At All / A Little Bit / Moderately / Quite
A
Bit / Extremely
G1. / Nervousness or shakiness inside / 0 / 1 / 2 / 3 / 4
G2. / Faintness or dizziness / 0 / 1 / 2 / 3 / 4
G3. / The idea that someone else can control your thoughts / 0 / 1 / 2 / 3 / 4
G4. / Feeling others are to blame for most of your troubles / 0 / 1 / 2 / 3 / 4
G5. / Trouble remembering things / 0 / 1 / 2 / 3 / 4
G6. / Feeling easily annoyed or irritated / 0 / 1 / 2 / 3 / 4
G7. / Pains in the heart or chest / 0 / 1 / 2 / 3 / 4
G8. / Feeling afraid in open spaces or on the streets / 0 / 1 / 2 / 3 / 4
G9. / Thoughts of ending your life / 0 / 1 / 2 / 3 / 4
G10. / Feeling that most people cannot be trusted / 0 / 1 / 2 / 3 / 4
G11. / Poor appetite / 0 / 1 / 2 / 3 / 4
G12. / Suddenly feeling scared for no reason / 0 / 1 / 2 / 3 / 4
G13. / Temper outbursts that you could not control / 0 / 1 / 2 / 3 / 4
G14. / Feeling lonely even when you are with people / 0 / 1 / 2 / 3 / 4
G15. / Feeling blocked in getting things done / 0 / 1 / 2 / 3 / 4
Not At All / A Little Bit / Moderately / Quite A Bit / Extremely
G16. / Feeling lonely / 0 / 1 / 2 / 3 / 4
G17. / Feeling blue / 0 / 1 / 2 / 3 / 4
G18. / Feeling no interest in things / 0 / 1 / 2 / 3 / 4
G19. / Feeling fearful / 0 / 1 / 2 / 3 / 4
G20. / Your feelings being easily hurt / 0 / 1 / 2 / 3 / 4
G21. / Feeling that people are unfriendly or dislike you / 0 / 1 / 2 / 3 / 4
G22. / Feeling inferior to others / 0 / 1 / 2 / 3 / 4
G23. / Nausea or upset stomach / 0 / 1 / 2 / 3 / 4
G24. / Feeling that you are watched or talked about by others / 0 / 1 / 2 / 3 / 4
G25. / Trouble falling to sleep / 0 / 1 / 2 / 3 / 4
G26. / Having to check and double check what you do / 0 / 1 / 2 / 3 / 4
G27. / Difficulty making decisions / 0 / 1 / 2 / 3 / 4
G28. / Feeling afraid to travel on buses, subways, or trains / 0 / 1 / 2 / 3 / 4
G29. / Trouble getting your breath / 0 / 1 / 2 / 3 / 4
G30. / Hot or cold spells / 0 / 1 / 2 / 3 / 4
G31. / Having to avoid certain things, places, or activities because they frighten you / 0 / 1 / 2 / 3 / 4
G32. / Your mind going blank / 0 / 1 / 2 / 3 / 4
G33. / Numbness or tingling in parts of your body / 0 / 1 / 2 / 3 / 4
G34. / The idea that you should be punished for your sins / 0 / 1 / 2 / 3 / 4
Not At All / A Little Bit / Moderately / Quite A Bit / Extremely
G35. / Feeling hopeless about the future / 0 / 1 / 2 / 3 / 4
G36. / Trouble concentrating / 0 / 1 / 2 / 3 / 4
G37. / Feeling weak in parts of your body / 0 / 1 / 2 / 3 / 4
G38. / Feeling tense or keyed up / 0 / 1 / 2 / 3 / 4
G39. / Thoughts of death or dying / 0 / 1 / 2 / 3 / 4
G40. / Having urges to beat, injure, or harm someone / 0 / 1 / 2 / 3 / 4
G41. / Having urges to break or smash things / 0 / 1 / 2 / 3 / 4
G42. / Feeling very self-conscious with others / 0 / 1 / 2 / 3 / 4
G43. / Feeling uneasy in crowds, such as shopping or at a movie / 0 / 1 / 2 / 3 / 4
G44. / Never feeling close to another person / 0 / 1 / 2 / 3 / 4
G45. / Spells of terror or panic / 0 / 1 / 2 / 3 / 4
G46. / Getting into frequent arguments / 0 / 1 / 2 / 3 / 4
G47. / Feeling nervous when you are left alone / 0 / 1 / 2 / 3 / 4
G48. / Others not giving you proper credit for your achievements / 0 / 1 / 2 / 3 / 4
G49. / Feeling so restless you couldn’t sit still / 0 / 1 / 2 / 3 / 4
G50. / Feelings of worthlessness / 0 / 1 / 2 / 3 / 4
G51. / Feeling that people will take advantage of you if you let them / 0 / 1 / 2 / 3 / 4
G52. / Feelings of guilt / 0 / 1 / 2 / 3 / 4
G53. / The idea that something is wrong with your mind / 0 / 1 / 2 / 3 / 4
/ The next questions ask about thoughts, feelings, and experiences you may have had in your lifetime. For each question, please answer yes or no. / No / Yes
G54. / Have you ever wished you were dead? / 0 / 1
G55. / Have you felt like life was not worth living? / 0 / 1
G56. / Have you felt like hurting yourself? / 0 / 1
G57. / Have you felt like killing yourself? / 0 / 1
G58. / Have you ever given up hope for your life? / 0 / 1