Below are a few introductory questions pertaining to the study. Please answer them to the best of your ability, with the answers that most accurately reflect yourself.  

1. First Name:
2. Age:
3. Gender:

 

4. Email:
5. Phone:

 

4. Would you be comfortable being videotaped while you discuss happy and sad emotional events from your life?  Yes No

 

5. Has there been any time in your life when you had five or more drinks (beer, wine, or liquor) on one occasion?  Yes No Maybe

 

6. Have you ever used street drugs?  Yes No Maybe

 

7. Have you ever gotten “hooked” on a prescribed medicine or taken a lot more of it than you were supposed to?  Yes No Maybe

 

8. Have you ever had a panic attack, when you suddenly felt frightened or anxious, or suddenly developed a lot of physical symptoms?  Yes No Maybe

 

9. Were you ever afraid of going out of the house alone, being in crowds, standing in a line, or traveling on buses or trains?  Yes No Maybe

 

10. Is there anything that you have been afraid to do or felt uncomfortable doing in front of other people, like speaking, eating, or writing?  Yes No Maybe

 

11. Are there any other things that you have been especially afraid of, like flying, seeing blood, getting a shot, heights, closed places, or certain kinds of animals or insects?  Yes No Maybe

 

12. Have you been bothered by thoughts that didn’t seem reasonable, and kept coming back to you even when you tried not to have them?  Yes No Maybe

 

13. Is there anything that you have to do over and over again and can’t resist doing, such as washing your hands again and again, counting up to a certain number, or checking something several times to make sure that you’ve done it right?  Yes No Maybe

 

14. Over the last six months, have you been particularly nervous or anxious?  Yes No Maybe

 

15. Have you ever had a period of time when you felt depressed or down most of the day, nearly every day?  Yes No Maybe

 

16. Have you lost interest or pleasure in things that you usually enjoyed?  Yes No Maybe

 

17. Have you had any thoughts about hurting or killing yourself?  Yes No Maybe

 

18. Has there ever been a period of time when you felt so good, “high,” or hyper that other people thought you weren’t your normal self?  Yes No Maybe

 

19. Have you ever had a period when you were so irritable that you shouted at people or started fights or arguments?  Yes No Maybe

 

20. Have you ever heard things that other people couldn’t hear, such as noises or the voices of people talking or whispering?  Yes No Maybe

 

21. Have you ever seemed to be receiving special messages from TV, radio, or newspaper, or from how things are arranged around you?  Yes No Maybe

 

22. Have you ever experienced a very frightening or life-threatening situation like a major disaster, serious accident, fire, combat, physical assault, rape, sexual abuse, or seeing another person killed or badly hurt?  Yes No Maybe