The 12 items below refer to how you have feltand behaved DURING THE PAST MONTH. For each item, indicate the extent to which it is true, by checking the appropriate box next to the item.

1. I am concerned about a behavior, feeling, or something I am doing.

Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

2. This behavior or feeling has been getting worse in the past few weeks.

Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

3. I have tried stopping or reducing this behavior or feeling on my own.

Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

4. My attempts at stopping or reducing this behavior or feeling have been successful.

Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

5. I rely on my friends or family to help me with my current troubles.

Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

6. I am finding it more difficult to cope with things than usual.

Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

7. I am having trouble concentrating at work or school.

Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

8. I like to think things through or talk about things that bother me.

Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

9. I have talked to my family doctor or healthcare professional about the behavior or feeling that's troubling me.

Yes
No

10. I have talked to my friends or family about the behavior or feeling that's troubling me.

Yes
No

11. I have read books or went on the Internet to discover more about the behavior or feeling that's troubling me.

Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

12. I've been in therapy before and it's helped me.

Never
Yes, but it didn't help
Yes, somewhat
Yes, moderately
Yes, quite a lot
Yes, very much

 

Copyright 2002-2003 John M. Grohol. All rights reserved. For personal use only; other use may be prohibited by law.  

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Last reviewed:
  On 7 Sep 2006
  By John M. Grohol, Psy.D.