 In the past month, have you had the following thoughts, feelings, or experiences?

Check “yes” or “no” for each item.

Do not include experiences that occur only while under the influence of alcohol,
drugs or medications that were not prescribed to you.

If you answer “YES” to an item, also indicate how distressing that experience has
been for you.

Please note, all fields are required.

 1. Do familiar surroundings sometimes seem strange, confusing, threatening or

unreal to you?

o NO

o YES
 2. Have you heard unusual sounds like banging, clicking, hissing, clapping or
ringing in your ears?

o NO

o YES
 3. Do things that you see appear different from the way they usually do?

o NO

o YES
 4. Have you had experiences with telepathy, psychic forces, or fortune telling?

o NO

o YES
 5. Have you felt that you are not in control of your own ideas or thoughts?

o NO
o YES
 6. Do you have difficulty getting your point across, because you ramble or go off the
track a lot when you talk?

o NO

o YES
 7. Do you have strong feelings or beliefs about being unusually gifted or talented in
some way?

o NO

o YES
 8. Do you feel that other people are watching you or talking about you? Bạn có cảm
thấy người khác đang theo dõi hoặc nói về bạn không?

o NO

o YES
 9. Do you sometimes get strange feelings on or just beneath your skin, like bugs
crawling?

o NO

o YES
 10. Do you sometimes feel suddenly distracted by distant sounds that you are not
normally aware of?

o NO

o YES
 11. Have you had the sense that some person or force is around you, although you
couldn’t see anyone? Bạn có cảm giác rằng có ai đó hoặc thế lực nào đó đang ở
xung quanh bạn, mặc dù bạn không thể nhìn thấy ai không?
o NO

o YES
 12. Do you worry at times that something may be wrong with your mind?

o NO

o YES
 13. Have you ever felt that you don't exist, the world does not exist, or that you are
dead?

o NO

o YES
 14. Have you been confused at times whether something you experienced was real
or imaginary?

o NO

o YES
 15. Do you hold beliefs that other people would find unusual or bizarre?

o NO

o YES
 16. Do you feel that parts of your body have changed in some way, or that parts of
your body are working differently?

o NO

o YES
 17. Are your thoughts sometimes so strong that you can almost hear them?

o NO
o YES
 18. Do you find yourself feeling mistrustful or suspicious of other people?

o NO

o YES
 19. Have you seen unusual things like flashes, flames, blinding light, or geometric
figures?

o NO

o YES
 20. Have you seen things that other people can't see or don't seem to see?

o NO

o YES
 21. Do people sometimes find it hard to understand what you are saying?

o NO

o YES

1. Do you ever hear or see things that others cannot? *

Bạn có bao giờ nghe hoặc nhìn thấy những điều mà người khác không thể thấy
được không?

 Never

 Rarely

 Sometimes

 Often
 Very Often

2. Do you struggle to trust that what you are thinking is real? *

3. Do you get the sense that others are controlling your thoughts and emotions? *
Bạn có cảm giác rằng người khác đang kiểm soát suy nghĩ và cảm xúc của bạn không? *

4. Do you struggle to keep up with daily living tasks such as showering, changing clothes,
paying bills, cleaning, cooking, etc.? *

5. Do you feel that you have powers that other people cannot understand or appreciate? *
Bạn có cảm thấy mình có những năng lực mà người khác không thể hiểu hoặc
đánh giá cao không?

6. Do you find it difficult to organize or keep track of your thinking? *

7. Do other people say that it is difficult for you to stay on subject or for them to understand
you? *

8. Are you struggling with maintaining social relationships, employment, and/or academic
demands? *

Bạn có đang gặp khó khăn trong việc duy trì các mối quan hệ xã hội, việc làm
và/hoặc nhu cầu học tập không?

9. Do you feel that you are being tracked, followed, or watched at home or outside? *
Bạn có cảm thấy mình đang bị theo dõi, theo dõi ở nhà hay bên ngoài không?
10. Do other people have a difficult time guessing your emotions by your facial expressions? *

1/ I believe others control what I think or feel

Tôi tin rằng người khác kiểm soát những gì tôi nghĩ hoặc cảm nhận

2/ There are voices or people inside my head that talk to me and that no one else
can hear

Có những giọng nói hoặc những người ở trong đầu tôi nói chuyện với tôi mà không
ai khác có thể nghe thấy.

3/ I know others are out to get me or plotting against me

Tôi biết những người khác đang muốn hãm hại tôi hoặc đang âm mưu chống lại tôi.
4/ Sometimes I'm talking to the people or voices in my head, but others think I'm
talking to myself
Đôi khi tôi đang nói chuyện với mọi người hoặc những giọng nói trong đầu nhưng
người khác lại nghĩ rằng tôi đang nói chuyện với chính mình.