Master Questionnaire

Patient Screening Questionnaire
Name
First NameLast Name
Birth Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code

Rows	Never	Rarely	Occasionally	Frequently	Very Frequently	N/A
Fail to pay close attention to details or make careless mistakes
Trouble sustaining attention
Do not seem to listen when spoken to directly
Poor follow through
Disorganized
Avoid tasks that require sustained effort
Lose things
Easily distracted
Fidgety
Trouble sitting still
Restless
Unable to play or engage in leisure activities quietly
"On the go" or acting as if "driven by a motor"
Talks excessively
Blurt out answers before questions have been completed ( e.g., complete people’s sentences; cannot wait for turn in conversation)
Difficulty waiting (e.g., waiting in line)
Interrupts others
Make decisions or behave impulsively (saying or doing things without thinking)
Difficulty delaying what I want Accident prone, traffic violations or near accidents
Overwhelmed by the tasks of everyday life
Difficulty expressing feelings
Difficulty expressing empathy for others
Late or in a hurry
Get stuck on negative thoughts or behaviors
Recurrent bothersome thoughts or images I try to ignore
Compulsive behaviors (such as excessive hand washing, checking locks, counting, or spelling) to avoid feeling anxious
Upset when things do not go my way
Hold onto own opinion and do not seem to listen to others
Tend to say no without first thinking about the question
Need to be perfect
Insomnia or trouble sleeping
Irritable or easily agitated
Recent decrease in appetite or weight
Significant mood swings or cycles
Periods of very high self-esteem or grandiose thinking
Periods of being more talkative than usual of feeling pressure to keep talking
Easily distracted by irrelevant things
Excessive involvement in pleasurable activities that have a high risk for negative consequences (e.g., spending money, sexual indiscretions, or gambling)
Anxious, tense, or nervous
Panic attacks, which are periods of intense, unexpected fear or emotional discomfort
Fear of dying
Excessive motivation or can't stop working
Lack of confidence in abilities
Avoid everyday places for 1) fear of having a panic attack or 2) needing to go with other people in order to feel comfortable
Recurrent and upsetting thoughts of a past traumatic event (molestation, accident, fire, etc..)
Recurrent distressing dreams of a past upsetting event
Avoid activities/situations which remind me of past upsetting events
Unable to recall an important aspect of a past upsetting event
Feel that my future is shortened
Have a physical response to events that remind me of a past upsetting event (e.g., sweating, increased pulse, etc... when getting in a car if you have been in a car accident)
Excessive fear of being judged by others, which causes me to avoid or get anxious in situations
Persistent, excessive phobia (heights, closed spaces, specific animals, etc...)
Involuntary physical movements and/or motor tics (such as eye blinking, shoulder shrugging, head jerking, or picking)
Involuntary vocal sounds or verbal tics (such as coughing, puffing, blowing, whistling, or swearing)
Intense fear of gaining weight or becoming overweight even though I am underweight
Feel overweight, even though others say I am underweight
Purge food, such as self-induced vomiting or using laxatives or diuretics; partaking in strict dieting, or partaking in strenuous exercise
Overly concerned with my body shape and/or weight
Irritability, short fuse, or easily angered
Experience illusions, such as hearing sounds that are not there (e.g., muffled voices or shots being fired); visual distortions (e.g., seeing shadows or things get bigger or smaller than they really are); or smelling odors that are not present (e.g., burned rubber)
Periods of deja vu (the feeling of being somewhere you have never been)
Trouble reading the body language or facial expression of others
Trouble learning new information
Memory problems
Delusional or bizarre thoughts (thoughts I know others would think are false)
Auditory or visual hallucinations
Periods of time where my thoughts or speech were disjointed or didn't make sense to others
Make mistakes when reading, such as skipping words or lines
Have problems remembering what I read even though I have just read all the words
Light sensitive and bothered by glare, sunlight, headlights, or streetlights
Problems judging distance and have difficulty with such things as escalators, stairs, ball sports, or driving
Tend to keep notebook/paperwork/room messy or disorganized

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Patient Screening Questionnaire