Name: | Age: | Sex: Male | Date: | ||||
Instructions: For each statement below, please check (✓) the box that best answers each question to show how much each thing has happened to you in the past SEVEN (7) DAYS. | |||||||
CLINICIAN USE | |||||||
Not at all | Once or twice | Almost every day | About once a day | More than once a day | ITEM SCORE | ||
1. I find myself staring into space and thinking of nothing. | 0 | 1 | 2 | 3 | 4 | ||
2. People, objects, or the world around me seem strange or unreal. | 0 | 1 | 2 | 3 | 4 | ||
3. I find that I did things that I do not remember doing. | 0 | 1 | 2 | 3 | 4 | ||
4. When I am alone, I talk out loud to myself. | 0 | 1 | 2 | 3 | 4 | ||
5. I feel as though I were looking at the world through a fog so that people and things seem far away or unclear. | 0 | 1 | 2 | 3 | 4 | ||
6. I am able to ignore pain. | 0 | 1 | 2 | 3 | 4 | ||
7. I act so differently from one situation to another that it is almost as if I were two different people. | 0 | 1 | 2 | 3 | 4 | ||
8. I can do things very easily that would usually be hard for me. | 0 | 1 | 2 | 3 | 4 | ||
Total/partial raw score: | |||||||
Prorated total raw score: (if 1-2 items left unanswered) | |||||||
Average total score: |
آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟