Instructions: Please follow these instructions when answering the questionnaire: In the following table you will find a set of difficulties and problems which possibly describe you. Please work through the questionnaire and decide how much you suffered from each problem in the course of the last week. In case you have no feelings at all at the present moment, please answer according to how you think you might have felt. Please answer honestly. All questions refer to the last week. If you felt different ways at different times in the week, give a rating for how things were for you on average. Please be sure to answer each question. Name Business Email Phone Number 1. It was hard for me to concentrate Not at all A little Rather Much Very Strong None 2. I felt helpless Not at all A little Rather Much Very strong None 3. I was absent-minded and unable to remember what I was actually doing Not at all A little Rather Much Very strong None 4. I felt disgust Not at all A little Rather Much Very strong None 5. I thought of hurting myself Not at all A little Rather Much Very strong None 6. I didn't trust other people Not at all A little Rather Much Very strong None 7. I didn't believe in my right to live Not at all A little Rather Much Very strong None 8. I was lonely Not at all A little Rather Much Very strong None 9. I experienced stressful inner tension Not at all A little Rather Much Very strong None 10. I had images that I was very much afraid of Not at all A little Rather Much Very strong None 11. I hated myself Not at all A little Rather Much Very strong None 12. I wanted to punish myself Not at all A little Rather Much Very strong None 13. I suffered from shame Not at all A little Rather Much Very strong None 14. My mood rapidly cycled in terms of anxiety, anger, and depression Not at all A little Rather Much Very strong None 15. I suffered from voices and noises from inside and/or outside my head Not at all A little Rather Much Very strong None 16. Criticism had a devastating effect on me Not at all A little Rather Much Very strong None 17. I felt vulnerable Not at all A little Rather Much Very strong None 18. The idea of death had a certain fascination for me Not at all A little Rather Much Very strong None 19. Everything seemed senseless to me Not at all A little Rather Much Very strong None 20. I was afraid of losing control Not at all A little Rather Much Very strong None 21. I felt disgusted by myself Not at all A little Rather Much Very strong None 22. I felt as if I was far away from myself Not at all A little Rather Much Very strong None 23. I felt worthless Not at all A little Rather Much Very strong None 24. Now we would like to know in addition the quality of your overall personal state in the course of the last week. 0% means absolutely down, 100% means excellent. Please check the percentage which comes closest. Very Bad 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Excellent None 1 out of 24 Time's up
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