DSM-5-TR Self Rated Level 1 Cross-Cutting Symptom Measure – Adult Name(Required) Age(Required) Date(Required) MM slash DD slash YYYY If this questionnaire is completed by an informant, what is your relationship with the individual? In a typical week, approximately how much time do you spend with the individual? hours/weekInstructions: The questions below ask about things that might have bothered you. For each question, circle the number that best describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS. During the past TWO (2) WEEKS, how much (or how often) have you been bothered by the following problems?1. Little interest or pleasure in doing things?(Required) None - Not at all Slight - Rare, less than a day or two Mild - Several days Moderate - More than half the days Severe - Nearly every day Highest Domain Score - Clinician 2. Feeling down, depressed, or hopeless?(Required) None - Not at all Slight - Rare, less than a day or two Mild - Several days Moderate - More than half the days Severe - Nearly every day Highest Domain Score - Clinician 3. Feeling more irritated, grouchy, or angry that usual?(Required) None - Not at all Slight - Rare, less than a day or two Mild - Several days Moderate - More than half the days Severe - Nearly every day Highest Domain Score - Clinician 4. Sleeping less than usual, but still have a lot of energy?(Required) None - Not at all Slight - Rare, less than a day or two Mild - Several days Moderate - More than half the days Severe - Nearly every day Highest Domain Score - Clinician 5. Starting lots more projects than usual or doing more risky things than usual?(Required) None - Not at all Slight - Rare, less than a day or two Mild - Several days Moderate - More than half the days Severe - Nearly every day Highest Domain Score - Clinician 6. Feeling nervous, anxious, fightened, worried, or on edge?(Required) None - Not at all Slight - Rare, less than a day or two Mild - Several days Moderate - More than half the days Severe - Nearly every day Highest Domain Score - Clinician 7. Feeling panic or being frightened?(Required) None - Not at all Slight - Rare, less than a day or two Mild - Several days Moderate - More than half the days Severe - Nearly every day Highest Domain Score - Clinician 8. Avoiding situations that make you anxious?(Required) None - Not at all Slight - Rare, less than a day or two Mild - Several days Moderate - More than half the days Severe - Nearly every day Highest Domain Score - Clinician 9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)?(Required) None - Not at all Slight - Rare, less than a day or two Mild - Several days Moderate - More than half the days Severe - Nearly every day Highest Domain Score - Clinician 10. Feeling that your illnesses are not being taken seriously enough?(Required) None - Not at all Slight - Rare, less than a day or two Mild - Several days Moderate - More than half the days Severe - Nearly every day Highest Domain Score - Clinician 11. Thoughts of actually hurting yourself?(Required) None - Not at all Slight - Rare, less than a day or two Mild - Several days Moderate - More than half the days Severe - Nearly every day Highest Domain Score - Clinician 12. Hearing things other people couldn't hear, such as voices even when no one was around?(Required) None - Not at all Slight - Rare, less than a day or two Mild - Several days Moderate - More than half the days Severe - Nearly every day Highest Domain Score - Clinician 13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?(Required) None - Not at all Slight - Rare, less than a day or two Mild - Several days Moderate - More than half the days Severe - Nearly every day Highest Domain Score - Clinician 14. Problems with sleep that affected your sleep quality over all?(Required) None - Not at all Slight - Rare, less than a day or two Mild - Several days Moderate - More than half the days Severe - Nearly every day Highest Domain Score - Clinician 15. Problems with memony (e.g., learning new information) or with location (e.g., finding your way home)?(Required) None - Not at all Slight - Rare, less than a day or two Mild - Several days Moderate - More than half the days Severe - Nearly every day Highest Domain Score - Clinician 16. Unpleasant thoughts, urges, or images that repeatedly enter your mind?(Required) None - Not at all Slight - Rare, less than a day or two Mild - Several days Moderate - More than half the days Severe - Nearly every day Highest Domain Score - Clinician 17. Feeling driven to perform certain behaviors or mental acts over and over again?(Required) None - Not at all Slight - Rare, less than a day or two Mild - Several days Moderate - More than half the days Severe - Nearly every day Highest Domain Score - Clinician 18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?(Required) None - Not at all Slight - Rare, less than a day or two Mild - Several days Moderate - More than half the days Severe - Nearly every day Highest Domain Score - Clinician 19. Not knowing who you really are or what you want out of life?(Required) None - Not at all Slight - Rare, less than a day or two Mild - Several days Moderate - More than half the days Severe - Nearly every day Highest Domain Score - Clinician 20. Not feeling close to other people or enjoying your relationships with them?(Required) None - Not at all Slight - Rare, less than a day or two Mild - Several days Moderate - More than half the days Severe - Nearly every day Highest Domain Score - Clinician 21. Drinking atleast 4 drinks of any king of alcohol in a single day?(Required) None - Not at all Slight - Rare, less than a day or two Mild - Several days Moderate - More than half the days Severe - Nearly every day Highest Domain Score - Clinician 22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco?(Required) None - Not at all Slight - Rare, less than a day or two Mild - Several days Moderate - More than half the days Severe - Nearly every day Highest Domain Score - Clinician 23. Using any of the following medicines ON YOUR OWN, that is, without a doctor's prescription, in greated amounts or longer than prescribed [e.g., painkillers (like Vicodin), stimulants (like Ritalin or Adderall), sedatives or tranquilizers (like sleeping pills or Valium), or drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)]?(Required) None - Not at all Slight - Rare, less than a day or two Mild - Several days Moderate - More than half the days Severe - Nearly every day Highest Domain Score - Clinician Δ
