DIRECTIONS
These questions ask about different kinds of experiences that happen to people. For each question, circle the number that
tells how much that experience happens to you. Circle a "0" if it never happens to you, circle a "10" if it is always happening
to you. If it happens sometimes but not all of the time, circle a number between 1 and 9 that best describes how often it
happens to you. When you answer, only tell how much these things happen when you HAVE NOT had any alcohol or drugs.
Example:
0 1 2 3 4
5 6 7 8 9 10
(Never)
(Always)
1. I get so wrapped up in watching TV, or playing video games, that I don’t have any idea what’s going on around
me.
0 1 2 3 4
5 6 7 8 9 10
(Never)
(Always)
2. I get back tests or homework that I don’t remember doing.
0 1 2 3 4
5 6 7 8 9 10
(Never)
(Always)
3. I have strong feelings that don’t seem like they are mine.
0 1 2 3 4
5 6 7 8 9 10
(Never) (Always)
4. I can do something really well one time and then I can’t do it at all another time.
0 1 2 3 4
5 6 7 8 9 10
(Never)
(Always)
5. People tell me I do or say things that I don’t remember doing or saying.
0 1 2 3 4
5 6 7 8 9 10
(Never)
(Always)
6. I feel like I am in a fog or spaced out and things around me seem unreal.
0 1 2 3 4
5 6 7 8 9 10
(Never) (Always)
7. I get confused about whether I have done something or only thought about doing it.
0 1 2 3 4
5 6 7 8 9 10
(Never) (Always)
8. I look at the clock and realize that time has gone by and I can’t remember what has happened.
0 1 2 3 4
5 6 7 8 9 10
(Never)
(Always)
9. I hear voices in my head that are not mine.
0 1 2 3 4
5 6 7 8 9 10
(Never)
(Always)
10. When I am somewhere that I don’t want to be, I can go away in my mind.
0 1 2 3 4
5 6 7 8 9 10
(Never) (Always)
11. I am so good at lying and acting that I believe it myself.
0 1 2 3 4
5 6 7 8 9 10
(Never)
(Always)
12. I catch myself "waking up" in the middle of doing something.
0 1 2 3 4
5 6 7 8 9 10
(Never)
(Always)
13. I don’t recognize myself in the mirror.
0 1 2 3 4
5 6 7 8 9 10
(Never)
(Always)
14. I find myself going somewhere or doing something and I don’t know why.
0 1 2 3 4
5 6 7 8 9 10
(Never)
(Always)
15. I find myself someplace and don’t remember how I got there.
0 1 2 3 4
5 6 7 8 9 10
(Never)
(Always)
16. I have thoughts that don’t really seem to belong to me.
0 1 2 3 4
5 6 7 8 9 10
(Never) (Always)
17. I find that I can make physical pain go away.
0 1 2 3 4
5 6 7 8 9 10
(Never) (Always)
18. I can’t figure out if things really happened or if I only dreamed or thought about them.
0 1 2 3 4
5 6 7 8 9 10
(Never) (Always)
19. I find myself doing something that I know is wrong, even when I really don’t want to do it.
0 1 2 3 4
5 6 7 8 9 10
(Never)
(Always)
20. People tell me that I sometimes act so differently that I seem like a different person.
0 1 2 3 4
5 6 7 8 9 10
(Never)
(Always)
21. It feels like there are walls inside of my head.
0 1 2 3 4
5 6 7 8 9 10
(Never)
(Always)
22. I find writings, drawings or letters that I must have done but I can’t remember doing.
0 1 2 3 4
5 6 7 8 9 10
(Never)
(Always)
23. Something inside of me seems to make me do things that I don’t want to do.
0 1 2 3 4
5 6 7 8 9 10
(Never)
(Always)
24. I find that I can’t tell whether I am just remembering something or if it is actually happening to me.
0 1 2 3 4
5 6 7 8 9 10
(Never)
(Always)
25. I find myself standing outside my body, watching myself as if I were another person.
0 1 2 3 4
5 6 7 8 9 10
(Never)
(Always)
26. My relationships with my family and friends change suddenly and I don’t know why.
0 1 2 3 4
5 6 7 8 9 10
(Never)
(Always)
27. I felt like my past is a puzzle and some of the pieces are missing.
0 1 2 3 4
5 6 7 8 9 10
(Never)
(Always)
28. I get so wrapped up in my toys or stuffed animals that they seem alive.
0 1 2 3 4
5 6 7 8 9 10
(Never)
(Always)
29. I feel like there are different people inside of me.
0 1 2 3 4
5 6 7 8 9 10
(Never)
(Always)
30. My body feels as if it doesn’t belong to me.
0 1 2 3 4
5 6 7 8 9 10
(Never) (Always)
