1. Obsessive Compulsive Disorder Assessment

This is a survey for adults and for children age twelve and older. Parents should provide assistance to children and teens.

Please answer all questions as best as you can. The survey will take 10-30 minutes. This information is very important to have completed for your first appointment.

Many of the questions ask you to rate your symptoms. Rating isn't always easy. To make it easier for you, choose the response that is true for you most of the time, or choose a response that is an average of what you experience.

Since symptoms of OCD can come and go, rate your symptoms for how you have been feeling for the last 30 days.

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1. Your first name:

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2. Last 4 digits of your cell phone number:

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3. Your therapist's name:

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4. Please share the history of your symptoms. For example, when did you first experience symptoms and when did the most recent episode begin?

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5. This section is about "Obsesions" (intrusive upsetting thoughts or images):

  1. None, Not at all 2. A little or Mildly 3. Some or moderately 4. Substantial or Severely 5. Extremely
How much do obsessions interfere with your daily activities:
How distressed are you from the obsessions:
How hard do you try to stop the obsessions:
How much control do you have over obsessions:

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6. How much time during the day do you experience obsessions?

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7. This section is about "Compulsions" (the urge to do a certain behavior or mental act)

  1. None, Not at all 2. A little or Mildly 3. Some or moderately 4. Substantial or Severely 5. Extremely
How much do compulsions interfere with your daily activities:
How distressed are you from the compulsions:
How hard do you try to stop the compulsions:
How much control do you have over compulsions:

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8. How much time during the day do you experience compulsions (urge or behavior)?

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9. What are some of your compulsions?

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10. Anxiety:

  Yes No
I have anxiety and it bothers me
I have panic attacks and they bother me
I feel like I'm going to go crazy or have a "nervous breakdown"
I feel like I'm going to have a heart attack
I feel like I'm going to faint

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11. Let me know about any patterns or trends with your OCD symptoms in the box below (seasonal, stress, illness).

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12. Please select True or False for each question below.
If you are not sure, then select "Don't know."
If you answer True to any question, please briefly explain it in the comments box below.

  True False Don't know
I have a parent(s) with OCD:
I have a sibling with OCD"
I have been the victim of a trauma:
I have had a serious illness:
I have witnessed a trauma:
I have witnessed a serious illness:
I watched very scary movies at a young age:
I had a parent who was verbally or physically aggressive:
I had a parent who was addicted to drugs or alcohol:
I have a spouse who is verbally or physically aggressive:
I have a spouse who is addicted to drugs or alcohol:
I had parent or grandparent who hoarded things:
I have had strep throat in the last 6 months:
I have "tics" or sudden jerks in my arms, legs, neck, shoulders, or other places:
I have been diagnosed with Tourettes:
I have a parent(s) with Tourettes:

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13. Please rate how true each item below is for your:

  Not true Somewhat true Very True Completely true
I find my obsessions to be reasonable or realistic.
I find my compulsions to be reasonable or realistic.
I feel a need to resolve my obsessive thoughts.
I am shy or introverted.
I am outgoing or extroverted.
I avoid conflict with my boss or teachers.
I avoid conflict with my parents or spouse.
I experience doubt about my behaviors or who I am.
I am a perfectionist.
I like to think about things.
I have a good imagnation.
I have high moral standards.
I have trouble initiating a task or activity.
I have trouble with follow-through.
I have trouble multitasking.
I feel secure or safe with everything in my life.
I procrastinate.
I feel sad or down.
I feel happy and cheerful.
I am lethargic and unmotivated.
I am energetic and motivated.
I like to be in control.

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14. Please select "current" or "past" or both options for the general categories of obsessions:

  Current Past
Contamination (germs, etc...)
Disasters or Catastrophies
Illnesses or health problems
Violence towards self or others
Religious or spiritual
Sexual or sexual orientation
Symmetry and Organization
Other (explain in comments box)

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15. How much has OCD impacted each area of your life listed below. Please rate each item.

  No problems, doing just fine Mild problems, a little difficulty Moderate problems, very noticeable Severe problems (fired, failing, withdrawn)
Social life
Work performance
Family relationships
Taking care of self

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16. Please share what you think causes OCD.

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