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Screening Visit

Screening

PANAS Questionnaire

Submitted by Lab on Mon, 03/18/2013 - 18:30

This scale consists or a number of words that describe different feelings and emotions. Read each item and then list the number from the scale below next to each word. Indicate to what extent you feel this way right now, that is, at the present moment OR indicate the extent you have felt this way over the past week (please indicate which instructions you followed when taking this measure).

Please choose an instruction set to follow. *

The present moment

Over the past week

Questionnaire

1= Very Slightly or Not at All 2= A Little 3= Moderately 4= Quite a Bit 5= Extremely

Interested *

Distressed *

Excited *

Upset *

Strong *

Guilty *

Scared *

Hostile *

Enthusiastic *

Proud *

Irritable *

Alert *

Ashamed *

Inspired *

Nervous *

Determined *

Attentive *

Jittery *

Active *

Afraid *

Read more about PANAS Questionnaire

Current Symptoms Scale: Self- report Daily

Submitted by Lab on Mon, 03/18/2013 - 17:59

Instructions: Please choose the number next to each item that best describes your behavior today. Indicate choices using 0=never, 1=rarely, 2=sometimes, 3=often, 4=always.

1. Fail to give close attention to details or make careless mistakes in my work (e.g. overlook or miss details, my work is inaccurate. *

2. Fidget with or tap hands or feet or squirm in seat. *

3. Have difficulty sustaining my attention in tasks or fun activities. *

4. Leave my seat in situations in which seating is expected. *

5. Don't listen when spoken to directly. *

6. Feel restless. *

7. Don't follow through on instructions and fail to finish work. *

8. Have difficulty engaging in leisure activities or doing fun things quietly. *

9. Have difficulty organizing tasks and activities. *

10. Feel "on the go" or "driven by a motor." *

11. Avoid, dislike, or am reluctant to engage in work that requires sustained mental effort. *

12. Talk Excessively. *

13. Often lose things necessary for tasks or activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, or mobile telephones). *

14. Often blurt out an answer before a question has been completed (e.g. complete people's sentences and "jump the gun" in conversations, cannot wait for next turn in conversations). *

15. Often easily distracted by extraneous stimuli (or unrelated thoughts). *

16. Often have difficulty waiting in turn (e.g. while waiting in line). *

17. Often forgetful in daily activities (e.g. chores, running errands, returning calls, paying bills, keeping appointments). *

18. Often interrupts or intrudes on others (e.g. butts into conversations, games, or activities; may start using other people's things without asking or receiving permission, intrude into or take over what others are doing). *

Read more about Current Symptoms Scale: Self- report Daily

Response Styles Questionnaire

Submitted by Lab on Mon, 03/18/2013 - 17:41

Instructions: People think and do many different things when they feel sad, blue, or depressed. You are going to read a list of possibilities. Please indicate if you 0=never, 1=sometimes, 2=often, or 3=always do this or do each one today. Please indicate what you do, not what you think you should do.

Questions.

1. Think about how alone you feel. *

2. Think "I wont be able to do my job if I don't snap out of this." *

3. Think about your feelings of fatigue and achiness. *

4. Think about how hard it is to concentrate. *

5. Think "what am I doing to deserve this? *

6. Think about how passive and unmotivated you feel. *

7. Analyze recent events to try to understand why you are depressed. *

8. Think about how you don't seem to feel anything anymore. *

9. Think "Why can't I get going?" *

10. Think "Why do I always react this way?" *

11. Go away by yourself and think about why you feel this way. *

12. Write down what you are thinking and analyze it. *

13. Think about a recent situation, wishing it had gone better. *

14. Think "I won't be able to concentrate if I keep feeling this way." *

15. Think "Why do I have problems other people don't have?" *

16. Think "Why can't I handle things better?" *

17. Think about how sad you feel. *

18. Think about all your shortcomings, failings, faults, mistakes. *

19. Think about how you don't feel up to doing anything. *

20. Analyze your personality to try to understand why you are depressed. *

21. Go someplace alone to think about your feelings. *

22. Think about how angry you are with yourself. *

Read more about Response Styles Questionnaire

Toronto Empathy Questionnaire

Submitted by Lab on Mon, 03/18/2013 - 14:29

Instructions: Below is a list of statements. Please read each statement carefully and rate how frequently you felt or acted in the manner described today. Circle your answer using the numbers to the right. There are no right or wrong answers or trick questions. Please answer each question as honestly as you can.
0 = never
1 = rarely
2 = sometimes
3 = often
4 = always

When someone else is feeling excited, I tend to get excited too. *

Other People's misfortunes do not disturb me a great deal. *

It upsets me to see someone being treated disrespectfully. *

I remain unaffected when someone close to me is happy. *

I enjoy making other people feel better. *

I have tender, concerned feelings for people less fortunate than me. *

When a friend starts to talk about his/her problems, I try to steer the conversation towards something else. *

I can tell when others are sad even when they do no say anything. *

I find that I am "in tune" with other people's moods. *

I do not feel sympathy for people who cause their own serious illnesses. *

I become irritated when someone cries. *

I am not really interested in how other people feel. *

I get a strong urge to help when I see someone who is upset. *

When I see someone being treated unfairly, I do not feel very much pity for them. *

I find it silly for people to cry out of happiness. *

When I see someone being taken advantage of, I feel kind of protective towards him or her. *

Read more about Toronto Empathy Questionnaire

Current Symptoms Scale: Self- report for Visit 1

Submitted by Lab on Mon, 03/18/2013 - 11:06

Instructions: Please choose the number next to each item that best describes your behavior during the past 6 months. Indicate using 0= Never or Rarely 1= Sometimes 2= Often 3= Very Often

1. Fail to give close attention to details or make careless mistakes in my work (e.g. overlook or miss details, my work is inaccurate). *

2. Fidget with or tap hands or feet or squirm in seat. *

3. Have difficulty sustaining my attention in tasks or fun activities. *

4. Leave my seat in situations in which seating is expected. *

5. Don't listen when spoken to directly. *

6. Feel restless. *

7. Don't follow through on instructions and fail to finish work. *

8. Have difficulty engaging in leisure activities or doing fun things quietly. *

9. Have difficulty organizing tasks and activities. *

10. Feel "on the go" or "driven by a motor." *

11. Avoid, dislike, or am reluctant to engage in work that requires sustained mental effort. *

12. Talk Excessively. *

13. Often lose things necessary for tasks or activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, or mobile telephones.) *

14. Often blurt out an answer before a question has been completed (e.g. complete people's sentences and "jump the gun" in conversations, cannot wait for next turn in conversations). *

15. Often easily distracted by extraneous stimuli (or unrelated thoughts). *

16. Often have difficulty waiting for turn (e.g. while waiting in line). *

17. Often forgetful in daily activities (e.g. chores, running errands, returning calls, paying bills, keeping appointments). *

How old were you when these problems with attention, impulsiveness, or hyperactivity first began to occur? *

If you do not have any of these, please say so.

To what extent do the problems you just circled interfere with your ability to function in each of these areas of life activities?

0= Never or Rarely 1= Sometimes 2= Often 3= Very Often

In my home life with my immediate family *

In my work or occupation *

In my social interactions with others *

In my activities or dealings in the community *

In any educational activities *

In my dating and marital relationships *

In my management of my money *

In my driving of a motor vehicle *

In my leisure or recreational activities *

In my management of my daily responsibilities *

Instructions: Again, please choose the number next to each item that best describes your behavior during the past 6 months.

0= Never or Rarely 1= Sometimes 2= Often 3= Very Often

1. Lose temper *

2. Argue *

3. Actively defy or refuse to comply with requests or rules *

4. Deliberately annoy people *

5. Blame others for my mistakes or misbehavior *

6. Am touchy or easily annoyed by others *

7. Am angry or resentful *

8. Am spiteful or vindictive *

Read more about Current Symptoms Scale: Self- report for Visit 1

Driving Behavior Survey- Self-Report Form.

Submitted by Lab on Sun, 03/17/2013 - 14:58

Instructions: For each item below, please select the number next to each item that represents how frequently you believe that you use each driving skill during your typical driving performance.
1 being not at all or rarely; 2 being sometimes, 3 being often and 4 being very often.

Prior to starting the car, I check all mirrors, adjust the seer (when necessary) and put on the seat belt. *

When moving in traffic, I check oncoming traffic, wait my turn, and accelerate properly. *

I use directional (turn) signals prior to making a turn or changing lanes. *

I turn around and check directly through the windshield for any obstacles or people in my way before backing up. *

I look directly through the left or right passenger side windows to check my "blind" spots before changing lanes. *

I drive at a rate of speed that is within the speed limits. *

I drive within the marked lane o a highway, and stay on my side of the road on two-lane roads. *

I avoid driving in the breakdown lanes or on road shoulders unnecessarily. *

I yield the right of way to other drivers at intersections and traffic rotaries. *

I react quickly and properly to brake lights when activated on vehicles ahead. *

I watch ahead of cars in front of me for obstacles that may be in the road. *

I observe and respond appropriately to traffic signals (e.g. slow at yellow, stop at red). *

I adjust speed to bad weather conditions affecting traffic and the roadway. *

I drive at an appropriate distance from vehicles ahead of me (at least one car length for each 10 miles per hour of speed). *

I brake smoothly to stop at marked intersections as required. *

I maintain two hands on the steering wheel while driving. *

I drive slowly at an appropriate speed when backing up (in reverse gear). *

I notice and obey posted traffic signs (stop, yield, school zones, merge, etc). *

I follow posted route markers (I do not get lost while driving). *

When parking, I slow to a safe speed and park within the designated space. *

I maintain attention (eye contact) toward traffic and the road ahead of me while driving. *

I keep the volume of the car radio, tape player, or CD player at low enough levels that I can hear sirens or other cars' horns. *

I make sure that the passengers riding with me wear their seat belts. *

I refer to maps before driving through a new area or city. *

I slow down and move away from maintenance crews working on or near the roadway. *

Before entering any intersection, I check approaching traffic for safe entry. *

Please select the number that best describes you're overall driving performance (One being poor and ten being excellent): *

Read more about Driving Behavior Survey- Self-Report Form.

Delinquent Peers Questionnaire-USE THIS COPY

Submitted by Lab on Fri, 03/15/2013 - 15:53

Below is a list of questions. Please read each question carefully and circle your answer. Please answer each question as honestly as you can using the numbers 0=None, 1=A few, 2=Some, 3=Most

In the last six months, how many of your friends:

1. Used a weapon or force to get money or things from people? *

2. Attacked someone with a weapon or with the idea of seriously hurting them? *

3. Hit someone with the idea of hurting them? *

4. Stole something worth more than $100? *

5. Stole something worth more than $5 but less than $50? *

6. Damaged or destroyed someone else's property on purpose? *

7. Took a car or motorcycle for a ride or drive without the owner's permission? *

8. Skipped classes without an excuse? *

In the last month, how many of your friends:

1. Used a weapon or force to get money or things from people? *

2. Attacked someone with a weapon or with the idea of seriously hurting them? *

3. Hit someone with the idea of hurting them? *

4. Stole something worth more than $100? *

5. Stole something worth more than $5 but less than $50? *

6. Damaged or destroyed someone else's property on purpose? *

7. Took a car or motorcycle for a ride or drive without the owner's permission? *

8. Skipped classes without an excuse? *

Read more about Delinquent Peers Questionnaire-USE THIS COPY

Perceived Stress Scale

Submitted by Lab on Fri, 03/15/2013 - 15:30

The questions in this scale ask you about your feelings and thoughts during the last month. In each case, you will be asked to indicate by circling how often you felt or thought a certain way. Indicate choices using 0 = Never, 1 = Almost Never, 2 = Sometimes, 3 = Fairly Often, 4 = Very Often

Date *

Month

Day

Year

Age *

Gender *

Male

Female

Other *

1. In the last month, how often have you been upset because of something that happened unexpectedly? *

2. In the last month, how often have you felt that you were unable to control the important things in your life? *

3. In the last month, how often have you felt nervous and "stressed"? *

4. In the last month, how often have you felt confident about your ability to handle your personal problems? *

5. In the last month, how often have you felt that things were going your way? *

6. In the last month, how often have you found that you could not cope with all the things that you had to do? *

7. In the last month, how often have you been able to control irritations in your life? *

8. In the last month, how often have you felt that you were on top of things? *

9. In the last month, how often have you been angered because of things that were outside of your control? *

10. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them? *

Read more about Perceived Stress Scale

Externalizing Spectrum Inventory-160

Submitted by Lab on Sun, 03/10/2013 - 11:43

Instructions: Please read each item carefully and indicate whether you would consider each statement true or false using 1=True and 0=False.

1. I have had problems at work because I was irresponsible. *

2. I enjoy pushing people around sometimes. *

3. Things are more fun if a little danger is involved. *

4. I've enjoyed getting drunk now and then, just for fun. *

5. I sympathize with other's problems. *

6. I have lied to avoid paying back loans. *

7. I've snorted drugs. *

8. I've told lies about someone just to see how it would affect them. *

9. I've had urges to use marijuana that were hard to resist. *

10. I have stolen something out of a vehicle. *

11. I get in trouble for not considering the consequences of my actions. *

12. It's easy for me to relate to other people's emotions. *

13. I've smoked marijuana at parties. *

14. I control myself and think before I do something. *

15. It doesnt bother me to see someone else in pain. *

16. I've been hurt so many times I can't trust anymore. *

17.I don't see any point in worrying if what I do hurts someone else. *

18. I've brought a weapon into a fight. *

19. I have borrowed money with no thought of paying it back. *

20. I have missed work without bothering to call in. *

21. I seek out thrills almost everywhere I go. *

22. I've asked someone to help bail me out of debt. *

23. After trying to cut down on alcohol, I've had physical problems like sweating or feeling shaky. *

24. I do lots of things just to get a thrill. *

25. My drug use led to problems at school or work. *

26. I've injured someone to see them in pain. *

27. I sometimes insult people on purpose to get a reaction from them. *

28. People often abuse my trust. *

29. I feel bored a lot of the time. *

30. I have enjoyed smoking marijuana with friends. *

31. I've quit a job without giving two weeks notice. *

32. I get bored easily. *

33. I've had to drink more than i used to in order to get the same buzz. *

34. I 've gotten things from people by making them feel sorry for me. *

35. I've taken a drug like LSD or magic mushrooms. *

36. I don't lie very much. *

37. Other have told me they are concerned with my lack of self-control. *

38. I've used downes like Valium or Xanax for non-medical reasons. *

39. I've used a weapon against someone who insulted me. *

40. It doesn't bother me when people around me are hurting. *

41. I often get bored quickly and lose interest. *

42. I've often ended up drinking more than I should. *

43. At time i kept drinking alcohol even though it caused problems with my friends and family. *

44. I usually let people know when I'll be late. *

45. I have taken items from a store without paying for them. *

46. I've let people down who trusted me. *

47. When I wat something, I want it right now. *

48. I have robbed someone. *

49. I taunt people just to stir things up. *

50. I've gotten in trouble because I've missed too much school. *

51. I have gotten drunk. *

52. I have tried smoking marijuana. *

53. I've gone on drinking binges. *

54. I have taken money from someone else's purse or wallet without asking. *

55. I've lost control of my alcohol use. *

56. I have hit someone in the face or head in anger. *

57. I have never bought drugs. *

58. I gave up things i used to enjoy because of marijuana. *

59. I gave up things I used to enjoy because of drugs. *

60. I have lied to get someone to sleep with me. *

61. People I've worked for would describe me as highly reliable. *

62. I let others know if I'm running behind. *

63. My drinking has led to problems at home. *

64. I return insults. *

65. I have boken into a house, school or other building. *

66. I enjoy a good physical fight. *

67. At times, marijuana has bee more important to me than work, friends or school. *

68. I've used drugs when it might be hazardous, like while driving a car. *

69. People think of me as dependable. *

70. I quickly get bored if I don't have something to do. *

71. I keep appointments I make. *

72. One or more times in my life, I have beaten someone up for bothering me. *

73. I hate waiting to get things that I want. *

74. I have spread rumors about people who were competing with me. *

75. I've taken an illegal drug that gave me a rush and made me more awake. *

76. I have lost a friend because of irresponsible things I've done. *

77. I have snuck marijuana or hash into a public event. *

78. I rarely lie. *

79. I don't have much sympathy for people. *

80. I usually a lot think about decisions before I make them. *

81. When I say I'll do something, I always follow through. *

82. I've bought items used for smoking marijuana. *

83. Most of the time, I have good self-control. *

84. I've had legal problems because of my drug use. *

85. I've had legal problems because I couldn't resist my impulses. *

86. At times I've drunk enough alcohol to pass out. *

87. Many people consider me a rule breaker *

88. Even when I don't do anything wrong, I still get blamed for it. *

89. I don't mind if someone I dislike gets hurt. *

90. I've gotten high using marijuana. *

91. I have good control over myself. *

92. I've spent big parts of my day using marijuana. *

93. I've never taken illegal drugs. *

94. I have a hard time waiting patiently for things I want. *

95. Other have told me I'm a rebellious person. *

96. I have been in trouble with the police for physically hurting someone who angered me. *

97. My impulsiveness have caused problems with loved ones. *

98. At some point in my life, I couldn't get high from a drug dose that worked before. *

99. I have gotten money from people from threatening to tell their secrets. *

100. I think about things before I do them. *

101. When someone hits me, I hit back. *

102. How other people feel is important to me. *

103. My marijuana use led to legal problems *

104. I'm not one who drinks much. *

105. I have a habit of breaking rules. *

106. I don't drink. *

107. I like having a drink of alcohol to relax. *

108. I have taken a purse or wallet from someone who was carrying it. *

109. I get blamed for things I don't do. *

110. I often disobey rules. *

111. I don't care much if what I do hurts others. *

112. I have no interest in trying drugs. *

113. For me, honesty really is the best quality. *

114. I'm not someone who breaks rules. *

115. I have damaged someone's things because it was exciting. *

116. I jump into things without thinking. *

117. I often get in trouble for breaking rules. *

118. I would enjoying being in a high-speed chase. *

119. I gave up things I used to enjoy because of my drinking. *

120. My marijuana use has led to problems at home, work, or school. *

121. I have failed to show up to court when I was supposed to. *

122. I've gone out of my way to get marijuana. *

123. I have damaged somone's property because I was angry with them. *

124. I've broken something belonging to someone else to get back at them. *

125. I've hurt someone's feelings to get back at them. *

126. I've failed to make payments on a loan. *

127. I vandalized someone's house or things because they were rude to me. *

128. My drug use has caused problems with my family. *

129. I've knocked someone's things to the ground for fun. *

130. I plan before I act. *

131. I've made a fool of someone because it made me feel good. *

132. I have used more drugs for longer than I meant to. *

133. I have been in trouble with the law for something I did on impulse. *

134. I have smacked someone who upset me. *

135. I get blamed for things that I did not do wrong. *

136. People use me. *

137. I've taken drugs to get over the bad effects of quitting a drug. *

138. I don't drink at parties. *

139. My lack of self-control gets me in trouble. *

140. I have not tried drinking hard liquor. *

141. It's difficult for me to tell a lie. *

142. I get unfairly blamed for things. *

143. I have destroyed property just for kicks. *

144. I've often missed things I promise to attend. *

145. I have conned people to get money from them. *

146. I have broken into someone's home and taken things. *

147. I am sensitive to the feelings of others. *

148. I've broken the law to get money for drugs. *

149. I truly feel other's emotions. *

150. I'm not a drinker. *

151. I often act on immediate needs. *

152. I have bought marijuana. *

153. I like risky activities. *

154. I have stolen something worth more than $10. *

155. I'll take my chances at getting hurt if it means having more fun. *

156. When I want something, nothing else seems important. *

157. I've been fired from more than one job. *

158. After trying to cut down on drinking alcohol, I've felt sad or irritable. *

159. I'm honest with others. *

160. I've trembled and gotten sweaty when I stopped using drugs. *

Read more about Externalizing Spectrum Inventory-160

BFIS-LF: Self-Report

Submitted by Lab on Sun, 03/10/2013 - 11:27

How much difficulty do you have functioning effectively in each of these major life activities? That is, to what degree do you see yourself as being impaired in each of these life domains? Please indicate the number next to each item that best describes your difficulties in functioning DURING THE PAST 6 MONTHS with 0 meaning "not at all" and 9 meaning "severely impaired". If the situation does not apply to you (for instance, you don't drive a car, don't have children, don't live with anyone, etc.), indicate 888.

In your home life with your immediate family *

888

In getting chore completed at home and managing your household *

888

In your work or occupation *

888

In your social interactions with strangers and acquaintances *

888

In your relationships with friends *

888

in your activities in the community (church, clubs, social groups, organizations) *

888

In any educational activities (college, night classes, technical training, occupational training) *

888

In your marital, co-living or dating relationships *

888

In your management of your money, your bills and your debt *

888

In driving a motor vehicle and in your history of citations and accidents *

888

In your sexual activities and sex relations with others *

888

In your organization and management of your daily responsibilities *

888

In caring for yourself (dressing, bathing, and hygiene, eating, sleeping, etc) *

888

In maining your health (exercise, nutrition, preventative medical and dental care, etc.) *

888

In taking care of and raising your children *

888

Read more about BFIS-LF: Self-Report

martel.as.uky.edu

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Screening Visit

PANAS Questionnaire

Current Symptoms Scale: Self- report Daily

Response Styles Questionnaire

Toronto Empathy Questionnaire

Current Symptoms Scale: Self- report for Visit 1

Driving Behavior Survey- Self-Report Form.

Delinquent Peers Questionnaire-USE THIS COPY

Perceived Stress Scale

Externalizing Spectrum Inventory-160

BFIS-LF: Self-Report

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