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Circle the number, from 0 (never) to 4 (frequently), that represents the degree to which the following thoughts, feelings, and behaviors have bothered you during the past month.
0 |
= |
Never |
1 |
= |
Rarely |
2 |
= |
Sometimes |
3 |
= |
Often |
4 |
= |
Frequently |
THOUGHTS
1. |
Awfulizing (fantasizing the worst possible outcome) |
0 |
1 |
2 |
3 |
4 |
2. |
Blaming myself |
0 |
1 |
2 |
3 |
4 |
3. |
Blaming others |
0 |
1 |
2 |
3 |
4 |
4. |
Difficulty concentrating |
0 |
1 |
2 |
3 |
4 |
5. |
Holding grudges |
0 |
1 |
2 |
3 |
4 |
6. |
Thinking and rethinking the same situation |
0 |
1 |
2 |
3 |
4 |
7. |
Wishing I could “turn my mind off” |
0 |
1 |
2 |
3 |
4 |
8. |
Constantly criticizing other people or situations |
0 |
1 |
2 |
3 |
4 |
9. |
Worrying |
0 |
1 |
2 |
3 |
4 |
10. |
Thinking something is wrong with my mind |
0 |
1 |
2 |
3 |
4 |
11. |
Needing to be right |
0 |
1 |
2 |
3 |
4 |
12. |
Feeling out of control |
0 |
1 |
2 |
3 |
4 |
EMOTIONS
1. |
Afraid of specific places or circumstances |
0 |
1 |
2 |
3 |
4 |
2. |
Feeling like a victim |
0 |
1 |
2 |
3 |
4 |
3. |
Anxious |
0 |
1 |
2 |
3 |
4 |
4. |
Blue |
0 |
1 |
2 |
3 |
4 |
5. |
Lonely |
0 |
1 |
2 |
3 |
4 |
6. |
Irritable |
0 |
1 |
2 |
3 |
4 |
7. |
Wanting to throw things or hit people |
0 |
1 |
2 |
3 |
4 |
8. |
Guilty |
0 |
1 |
2 |
3 |
4 |
9. |
Feeling unfriendly |
0 |
1 |
2 |
3 |
4 |
10. |
Uptight |
0 |
1 |
2 |
3 |
4 |
11. |
Hopeless about the future |
0 |
1 |
2 |
3 |
4 |
12. |
Wanting to “pull the covers over my head” |
0 |
1 |
2 |
3 |
4 |
13. |
Feeling that other people don’t like me |
0 |
1 |
2 |
3 |
4 |
14. |
Upset over criticism |
0 |
1 |
2 |
3 |
4 |
BEHAVIORS
1. |
Nail or cuticle biting |
0 |
1 |
2 |
3 |
4 |
2. |
Using tobacco in any form |
0 |
1 |
2 |
3 |
4 |
3. |
Taking tranquilizers or “street” drugs to change mood |
0 |
1 |
2 |
3 |
4 |
4. |
Drinking alcoholic beverages |
0 |
1 |
2 |
3 |
4 |
5. |
Chewing gum or sucking candies |
0 |
1 |
2 |
3 |
4 |
6. |
Talking a lot |
0 |
1 |
2 |
3 |
4 |
7. |
Crying a lot |
0 |
1 |
2 |
3 |
4 |
8. |
Sleeping problems (too much or too little) |
0 |
1 |
2 |
3 |
4 |
9. |
Eating problems (too much or too little) |
0 |
1 |
2 |
3 |
4 |
10. |
Trouble communicating |
0 |
1 |
2 |
3 |
4 |
11. |
Avoiding responsibilities |
0 |
1 |
2 |
3 |
4 |
12. |
Too much caffeine |
0 |
1 |
2 |
3 |
4 |
Copyright © Jane Leserman, Ph.D., and Claudia Dorrington, 1986.
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