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:

MaleFemalePrefer not to Say
4. Email:
5. Phone:

 

6. Has there been any time in your life when you had five or more drinks (beer, wine, or liquor) on one occasion?
YesNoMaybe

 

7. Have you ever used street drugs?
YesNoMaybe

 

8. Have you ever gotten “hooked” on a prescribed medicine or taken a lot more of it than you were supposed to?
YesNoMaybe

 

9. Have you ever had a panic attack, when you suddenly felt frightened or anxious, or suddenly developed a lot of physical symptoms?
YesNoMaybe

 

10. Were you ever afraid of going out of the house alone, being in crowds, standing in a line, or traveling on buses or trains?
YesNoMaybe

 

11. Is there anything that you have been afraid to do or felt uncomfortable doing in front of other people, like speaking, eating, or writing?
YesNoMaybe

 

12. 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?
YesNoMaybe

 

13. 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?
YesNoMaybe

 

14. 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?
YesNoMaybe

 

15. Over the last six months, have you been particularly nervous or anxious?
YesNoMaybe

 

16. Have you ever had a period of time when you felt depressed or down most of the day, nearly every day?
YesNoMaybe

 

17. Have you lost interest or pleasure in things that you usually enjoyed?
YesNoMaybe

 

18. Have you had any thoughts about hurting or killing yourself?
YesNoMaybe

 

19. 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?
YesNoMaybe

 

20. Have you ever had a period when you were so irritable that you shouted at people or started fights or arguments?
YesNoMaybe

 

21. Have you ever heard things that other people couldn’t hear, such as noises or the voices of people talking or whispering?
YesNoMaybe

 

22. Have you ever seemed to be receiving special messages from TV, radio, or newspaper, or from how things are arranged around you?

YesNoMaybe

 

23. 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?
YesNoMaybe