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

Patient/Client First Name

Patient/Client Last Name

Age

Date

If this questionnaire is completed by an informant, what is your relationship with the individual?

In a typical week, approximately how much time do you spend with the individual? (hours/week)

Instructions: The questions below ask about things that might have bothered you. For each question, select the number that best describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS.

[e.g., painkillers (like Vicodin), stimulants (like Ritalin or Adderall), sedatives or tranquilizers (like sleeping pills or Valium), or drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)]

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