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Adult Self- Report for Ages 18-59

Submitted by Lab on Fri, 03/08/2013 - 12:24

IX. Below is a list of items that describe people.

For each item, please circle 0, 1, or 2 to describe yourself over the past 6 months. Please answer all items as well as you can, even if some do not seem to apply to you. 0= Not True, 1= Somewhat or Sometimes True, 2= Very True or Often True.

1. I am too forgetful *

2. I make good use of my opportunities *

3. I argue a lot *

4. I work up to my ability *

5. I blame others for my problems *

6. I use drugs (other than alcohol and nicotine) for nonmedical purposes *

If you answered yes to number 6, please describe

7. I brag *

8. I have trouble concentrating or paying attention for long *

9. I can't get my mind off certain thoughts *

If you said yes, please describe

10. I have trouble sitting still *

11. I am too dependent on others *

12. I feel lonely *

13. I feel confused or in a fog *

14. I cry a lot *

15. I am pretty honest *

16. I am mean to others *

17. I daydream a lot *

18. I deliberately try to hurt or kill myself *

19. I try to get a lot of attention *

20. I damage or destroy my things *

21. I damage or destroy things belonging to others *

22. I worry about my future *

23. I break rules at work or elsewhere *

24. I don't eat as well as I should *

25. I don't get along well with others *

26. I don't feel guilty after doing something I shouldn't *

27. I am jealous of others *

28. I get along badly with my family *

29. I am afraid of certain animals, situations, or a places *

If you answered 1 or 2 to question 29, please describe

30. My realtions with the opposite sex are poor *

31. I am afraid I might think or do something bad *

32. I feel that I have to be perfect *

33. I feel that no one loves me *

34. I feel that others are out to get me *

35. I feel worthless or inferior *

36. I accidentally get hurt a lot, accident- prone *

37. I get in many fights *

38. My relations with neighbors are poor *

39. I hang around people who get in trouble *

40. I hear sounds or voices that other people think aren't there *

If you answered 1 or 2 to number 40, please describe.

41. I am impulsive or act without thinking *

42. I would rather be alone than with others *

43. I lie or cheat *

44. I feel overwhelmed by my responsibilities *

45. I am nervouse or tense *

46. Parts of my body twitch or make nervous movements *

If you answered 1 or 2 to number 46, please describe

47. I lack self- confidence *

48. I am not liked by others *

49. I can do certain things better than other people *

50. I am too fearful or anxious *

51. I feel dizzy or lightheaded *

52. I feel too guilty *

53. I have trouble planning for the future *

54. I feel tired without good reason *

55. My moods swing between elation and depression *

57. I physically attack people *

58. I pick my skin or other parts of my body *

If you answered 1 or 2 to number 58, please describe

59. I fail to finish things I should do *

60. There is very little that I enjoy *

61. My work performance is poor *

62. I am poorly coordinated or clumsy *

63. I would rather be with older people than with people of my own age *

64. I have trouble setting priorities *

65. I refuse to talk *

66. I repeat certain acts over and over *

67. I have trouble making or keeping friends *

68. I scream or yell a lot *

69. I am secretive or keep things to myself *

70. I see things that other people think aren't there *

If you answered 1 or 2 to number 70, please describe

71. I am self- conscious or easily embarrassed *

72. I worry about my family *

73. I meet my responsibilities to my family *

74. I show off or clown *

75. I am too shy or timid *

76. My behavior is irresponsible *

77. I sleep more than most other people during day and/or night *

If you answered 1 or 2 to number 77, please describe

78. I have trouble making decisions *

79. I have a speech problem *

If you answered 1 or 2 to number 79, please describe

80. I stand up for my rights *

81. My behavior is very changeable *

82. I steal *

83. I am easily bored *

84. I do things that other people think are strange *

If you answered 1 or 2 to number 84, please describe

85. I have thoughts that other people would think are strange *

If you answered 1 or 2 to number 85, please describe

86. I am stubborn, sullen, or irritable *

87. My moods or feelings change suddenly *

88. I enjoy being with people *

89. I rush into things without considering the risks *

90. I drink too much alcohol or get drunk *

91. I think about killing myself *

92. I do things that may cause me trouble with the law *

If you answered 1 or 2 to number 92, please describe

93. I talk too much *

94. I tease others a lot *

95. I have a hot temper *

96. I think about sex too much *

97. I threaten to hurt people *

98. I like to help others *

99. I dislike staying in one place for very long *

100. I have trouble sleeping *

If you answered 1 or 2 to number 100, please describe

101. I stay away from my job even when I'm not sick or not on vacation *

102. I don't have much energy *

103. I am unhappy, sad, or depressed *

104. I am louder than others *

105. People think I am disorganized *

106. I try to be fair to others *

107. I feel that I can't succeed *

108. I tend to lose things *

109. I like to try new things *

110. I wish I were of the opposite sex *

111. I keep from getting involved with others *

112. I worry a lot *

113. I worry about my relations with the opposite sex *

114. I fail to pay my debts or meet other financial responsibilities *

115. I feel restless or fidgety *

116. I get upset too easily *

117. I have trouble managing money or credit cards *

118. I am too impatient *

119. I am not good at details *

120. I drive too fast *

121. I tend to be late for appointments *

122. I have trouble keeping a job *

123. I am a happy person *

In the past 6 months, about how many times per day did you use tobacco (including smokeless tobacco)?

Answer in times per day.

In the past 6 months, on how many days were you drunk?

In the past 6 months, on how many days did you use drugs for nonmedical purposes (including marijuana, cocaine, and other drugs, except alcohol and nicotine)?

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Adult Self- Report for Ages 18-59

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