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DSM-5 Level 1 Cross-Cutting Symptom Measure—Adult

If you have any issues filling out this intake please call the Brownsville Counseling and Training Clinic at (956) 882 - 7792 or the Edinburg Counseling and Training Clinic at (956) 665 - 5251.

Last Name

First Name

Age

Sex

Female
Male

Date of Birth

Contact Number

Email

Instructions: 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.

Depression

Depression
	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Little interest or pleasure in doing things	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Feeling down, depressed, or hopeless	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Feeling more irritated, grouchy, or angry than usual?	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Sleeping less than usual, but still have a lot of energy	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Starting lots more projects than usual or doing more risky things than usual	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Not feeling close to other people or enjoying your relationships with them?	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day

Anxiety

Anxiety
	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Feeling nervous, anxious, frightened, worried, or on edge?	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Feeling panic or being frightened?	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Avoiding situations that make you anxious?	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day

Other

Other
	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)?	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Feeling that your illnesses are not being taken seriously enough	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day

Behavior

Behavior
	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Thoughts of actually hurting yourself?	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Hearing things other people couldn't hear, such as voices even when no one was around?	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Drinking at least four drinks of any kind of alcohol in a single day?	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco?	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day

Stability

Stability
	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Problems with sleep that affected your sleep quality over all?	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Problems with memory (e.g. learning new information) or with location (e.g. finding your way home)?	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Unpleasant thoughts, urges, or images that repeatedly enter your mind?	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Feeling driven to perform certain behaviors or mental acts over and over again?	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Not knowing who you are or what you want out of life?	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day

Using any of the following medicines ON YOUR OWN, that is, without a doctor’s prescription, in greater amounts or longer than prescribed

Using any of the following medicines ON YOUR OWN, that is, without a doctor’s prescription, in greater amounts or longer than prescribed
	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Painkillers (like Vicodin)	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Stimulants (like Ritalin or Adderall)	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Sedatives or Tranquilizers (like sleeping pills or Valium)	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Drugs (like marijuana, cocaine or crack)	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Club drugs (like ecstasy)	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Hallucinogens (like LSD)	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Heroin	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Inhalants or Solvents (like glue)	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day
Methamphetamine (like speed)	None - Not at All	Slight - rare, less than a day or two	Mild - Several days	Modertate - more than half the days	Severe -Nearly every day