Part A . Please select a "NO" or "YES" answer for each of the following questions asked, based on your experiences in the past Month .
Have you been bothered by unpleasant thoughts or images that repeatedly enter your mind, such as:
1. Do you have concerns with contamination (dirt, germs, chemicals, radiation) or getting a serious illness such as AIDS? NO YES
2. Are you overconcerned with keeping objects (clothing, groceries, tools) in perfect order or arranged exactly? NO YES
3. Do you have mental images of death or other horrible events? NO YES
4. Do you have personally unacceptable religious or sexual thoughts? NO YES
Have you worried a lot about terrible things happening, such as:
5. Do you worry about fire, burglary, or flooding the house? NO YES
6. Do you worry about accidentally hitting a pedestrian with your car or letting it roll down the hill? NO YES
7. Do you worry about spreading an illness (i.e. giving someone AIDS)? NO YES
8. Do you worry about losing something valuable? NO YES
9. Do you worry about harm coming to a loved one because you weren't careful enough? NO YES
Have you worried about acting on an unwanted and senseless urge or impulse, such as:
10 .Are you concerned about physically harming a loved one, pushing a stranger in front of a bus, steering your car into oncoming traffic; inappropriate sexual contact; or poisoning dinner guests? NO YES
Have you felt driven to perform certain acts over and over again, such as:
11. Do you perform excessive or ritualized washing, cleaning, or grooming rituals? NO YES
12. Do you check light switches, water faucets, the stove, door locks, or your car's emergency brake? NO YES
13. Do you perform counting; arranging; "evening-up" behaviors (making sure socks are at same height)? NO YES
14. Do you collect useless objects or inspect the garbage before it is thrown out? NO YES
15. Do you repeat routine actions (going in/out of a chair, going through a doorway, re-lighting a cigarette) a certain number of times, or until it feels "just right?" NO YES
16. Do you need to touch objects or people? NO YES
17. Do you unnecessarily re-read or re-write; re-open envelopes before they are mailed? NO YES
18. Do you examine your body for signs of illness? NO YES
19. Do you avoid certain colors ("red" means blood), numbers ("l3" is unlucky), or names (those that start with "D" signify death) that are associated with dreaded events or unpleasant thoughts? NO YES
20. Do you feel a need to "confess" or repeatedly ask for reassurance that you said or did something correctly? NO YES
Part B . The following questions refer to the repeated thoughts, images, urges, or behaviors identified in Part A. Consider your experience during the past 30 days when selecting an answer. Select the most appropriate response that applies to you.
On average, how much time is occupied by these thoughts or behaviors each day?
None Mild (less than 1 hour) Moderate (1 to 3 hours) Severe (3 to 8 hours) Extreme (more than 8 hours)
How much distress do they cause you? None Mild Moderate Severe Extreme (disabling)
How hard is it for you to control them? Complete control Much control Moderate control Little control No control
How much do they cause you to avoid doing anything, going any place, or being with anyone? No avoidance Occasional avoidance Moderate avoidance Frequent and extensive avoidance Extreme avoidance (house-bound) How much do they interfere with school, work or your social or family life? None Slight interference Definitely interferes with functioning Much interference Extreme interference (disabling)