• Form

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Symptoms of inattention that have persisted for at least six months and represent your usual functioning:
  • Symptoms of hyperactivity-impulsivity that have persisted for at least six months and represent your usual functioning:

  • Symptoms of persistent or repetitive thoughts OR behaviors that you may feel compelled to do and distressed if you stop them. The symptoms represent a CHANGE from your usual functioning and occurred at ANYTIME in your life:

  • Thoughts, impulses or images:
  • Behaviors or mental acts:
  • Did the symptoms occur during a period of illicit drug, alcohol or prescription drug abuse or addiction?
  • Did the symptoms occur after a throat infection or physical illness with fever?
  • Symptoms that occurred after you were exposed to a traumatic event at ANYTIME in your life:
  • The traumatic event is persistently re-experienced in any of the following ways:
  • Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by any of the following:
  • Persistent symptoms of increased arousal (not present before the trauma), as indicated by any of the following:
  • Symptoms of depression that have been present during the same 2-week (or more) period and represent a CHANGE from your usual functioning at ANYTIME in your life:
  • Did the symptoms occur during a period of illicit drug, alcohol or prescription drug abuse or addiction?
  • Did the symptoms occur after the death of a loved one or loss of an important relationship?
  • Symptoms of euphoria/elation that have been present during the same period of at least 4-7 days and represent a CHANGE from your usual functioning at ANYTIME in your life:
  • Did the symptoms occur during a period of illicit drug, alcohol or prescription drug abuse or addiction?
  • Symptoms of excessive or hard to control worry and anxiety that represent a CHANGE from your usual functioning at ANYTIME in your life:
  • The anxiety and worry are associated with any of the following symptoms:
  • Did the symptoms occur during a period of illicit drug, alcohol or prescription drug abuse or addiction?

  • Symptoms of intense anxiety of sudden onset and brief duration that represent a CHANGE from your usual functioning and occurred at ANYTIME in your life:

  • A discrete period of intense fear or discomfort, in which any of the following symptoms developed abruptly and reached a peak within 10 minutes:
  • Do you have anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having another anxiety attack?
  • Did the symptoms occur during a period of illicit drug, alcohol or prescription drug abuse or addiction?
  • Should be Empty: