Professional Documents
Culture Documents
27.12.2007
S C L 90
L.R. Derogatis, R.S. Lipman, L.Covi
STUDY
[____]
1-4
GROUP
[__]
5-6
PATIENT
[___]
7-9
RATING DAY
[___]
10-12
[__]
13-14
CARD NUMBER
[_]
15
Birthday (dd.mm.yy)
[__:__:__]
16-21
[__:__:__]
22-27
First diagnosis
[___.__]
28-32
Second diagnosis
[___.__]
33-37
[_]
[__]
Age at onset
[_]
[___]
[_]
[___]
[_]
38
39-40
41
42-44
45
46-48
49
DATE (dd.mm.yy)
[__:__:__]
50-55
INTERVIEWER
[___]
56-58
[__]
59-60
[____________]
61-72
HOSPITAL
PATIENT ID (the hospitals internal PID)
2004
Psychiatric University Hospital Zurich, P.O. Box 1931, CH-8032 Zurich, Switzerland
27.12.2007
Attached is a list of problems and complaints that people have. Please read each one carefully.
After you have done so, please fill in the number (0 to 4, see below) which best describes how
much that problem has bothered or distressed you during the past 4 weeks including
today. Choose only one number for each problem and do not skip any items. If you change
your mind, erase your first answer and fill in the new one. All questionnaires will be treated
confidentially!
0 = not at all;
1 = a little bit;
Card number
[__]
13-14
How much were you bothered or distressed over the past 4 weeks by
1 Headaches
[_]
15
[_]
16
[_]
17
4 Faintness or dizziness
[_]
18
[_]
19
[_]
20
[_]
21
[_]
22
[_]
23
[_]
24
[_]
25
[_]
26
[_]
27
[_]
28
[_]
29
[_]
30
17 Trembling
[_]
31
[_]
32
19 Poor appetite
[_]
33
20 Crying easily
[_]
34
[_]
35
[_]
36
[_]
37
[_]
38
Psychiatric University Hospital Zurich, P.O. Box 1931, CH-8032 Zurich, Switzerland
27.12.2007
[_]
39
[_]
40
[_]
41
[_]
42
29 Feeling lonely
[_]
43
30 Feeling blue
[_]
44
[_]
45
[_]
46
33 Feeling fearful
[_]
47
[_]
48
[_]
49
[_]
50
[_]
51
[_]
52
[_]
53
[_]
54
[_]
55
[_]
56
[_]
57
[_]
58
[_]
59
[_]
60
[_]
61
[_]
62
[_]
63
[_]
64
[_]
65
[_]
66
[_]
67
[_]
68
55 Trouble concentrating
[_]
69
[_]
70
[_]
71
[_]
72
Psychiatric University Hospital Zurich, P.O. Box 1931, CH-8032 Zurich, Switzerland
27.12.2007
1-12 dupl
Card number
13-14
[_]
15
60 Overeating
[_]
16
[_]
17
[_]
18
[_]
19
[_]
20
[_]
21
[_]
22
[_]
23
[_]
24
[_]
25
[_]
26
[_]
27
[_]
28
[_]
29
[_]
30
[_]
31
[_]
32
[_]
33
[_]
34
79 Feeling of worthlessness
[_]
35
[_]
36
[_]
37
[_]
38
83 Feeling that people will take advantage of you if you let them
[_]
39
[_]
40
[_]
41
[_]
42
[_]
43
[_]
44
89 Feelings of guilt
[_]
45
[_]
46
Please go back and check that you have answered all questions.
[__]