Obsessive Compulsive Disorder Assessment – Personal Solutions Counseling

This is a survey for adults and for children age twelve and older. Parents should provide assistance to children and teens.
Please answer all questions as best as you can. The survey will take 10-30 minutes. This information is very important to have completed for your first appointment.
Many of the questions ask you to rate your symptoms. Rating isn’t always easy. To make it easier for you, choose the response that is true for you most of the time, or choose a response that is an average of what you experience.
Since symptoms of OCD can come and go, rate your symptoms for how you have been feeling for the last 30 days.

Your first name: *

Last four (4) digits of your cell phone number: *

Your terapist's name: *

Please share thhistory of your syptoms. For example, when did you first experience symptoms and when did the most recent episode begin? *

How much do obsessions (intrusive upsetting thoughts or images) interfere with your daily activities? *

How distressed are you from the obsessions (intrusive upsetting thoughts or images)? *

How hard do you try to stop the obsessions (intrusive upsetting thoughts or images)? *

How much control do you have over obsessions (intrusive upsetting thoughts or images)? *

Additional Info or Comments to add

How much time during the day do you experience obsessions (intrusive upsetting thoughts or images)? *

How much do compulsions (the urge to do a certain behavior or mental act) interfere with your daily activities? *

How distressed are you from the compulsions (the urge to do a certain behavior or mental act)? *

How hard do you try to stop the compulsions (the urge to do a certain behavior or mental act)? *

How much control do you have over compulsions (the urge to do a certain behavior or mental act)? *

Additional Info or Comments to add

How much time during the day do you experience complusions (the urge to do a certain behavior or mental act)? *

What are some of your compulsions (the urge to do a certain behavior or mental act)? *

Checking (eg., doors, outlets)
Preparing for something bad that could happen
Preventing something bad from happening
Organizing things
Counting, tapping, balancing (symmetry)
Seeking reassurance
Other (describe in box below)

Please describe other from above (if marked)

I have Anxiety and it bothers me *

I have panic attacks and they bother me *

I feel like I'm going to go crazy or have a "nervous breakdown" *

I feel like I'm going to have a heart attack *

I feel like I'm going to faint *

Any additional information about the Anxiety you experience:

Please let us know about any patterns or trends with your OCD symptoms in the box below (seasonal, stress, illness, etc)

I have a parent(s) with OCD: *

True
False
Not sure

I have a sibling with OCD: *

True
False
Not sure

I have been the victim of a trauma: *

True
False
Not sure

I have had a serious illness: *

True
False
Not sure

I have witnessed a trauma: *

True
False
Not sure

I have witnessed a serious illness: *

True
False
Not sure

I have watched very scary movies at a young age: *

True
False
Not sure

I had a parent who was verbally or physically aggressive: *

True
False
Not sure

I had a parent who was addicted to drugs or alcohol: *

True
False
Not sure

I have a spouse who is verbally or physically aggressive: *

True
False
Not sure

I have a spouse who is addicted to drugs or alcohol: *

True
False
Not sure

I had a grandparent who hoarded things: *

True
False
Not sure

I have had strep throat in the last six (6) months: *

True
False
Not sure

I have "tics" or sudden jerks in my arms, legs, neck, shoulders, or other places: *

True
False
Not sure

I have been diagnosed with Tourettes: *

True
False
Not sure

I have a parent(s) with Tourettes: *

True
False
Not sure

Please elaborate on any true answers from the above questions

I find my obsessions to be reasonable or realistic: *

Not True
Somewhat True
Very True
Completely True

I find my compulsions to be reasonable or realistic: *

Not True
Somewhat True
Very True
Completely True

I feel a need to resolve my obsessive thoughts: *

Not True
Somewhat True
Very True
Completely True

I am shy or introverted *

Not True
Somewhat True
Very True
Completely True

I am outgoing or extroverted *

Not True
Somewhat True
Very True
Completely True

I avoid conflict with my boss or teachers *

Not True
Somewhat True
Very True
Completely True

I experience doubt about my behaviors or who I am *

Not True
Somewhat True
Very True
Completely True

I am a perfectionist *

Not True
Somewhat True
Very True
Completely True

I like to think about things *

Not True
Somewhat True
Very True
Completely True

I have a good imagination *

Not True
Somewhat True
Very True
Completely True

I have high moral standards *

Not True
Somewhat True
Very True
Completely True

I have trouble initiating a task or activity *

Not True
Somewhat True
Very True
Completely True

I have trouble with follow-through *

Not True
Somewhat True
Very True
Completely True

I have trouble multitasking *

Not True
Somewhat True
Very True
Completely True

I feel secure or safe with everything in my life *

Not True
Somewhat True
Very True
Completely True

I procrastinate *

Not True
Somewhat True
Very True
Completely True

I feel sad or down *

Not True
Somewhat True
Very True
Completely True

I feel happy and cheerful *

Not True
Somewhat True
Very True
Completely True

I am lethargic and unmotivated *

Not True
Somewhat True
Very True
Completely True

I am energetic and motivated *

Not True
Somewhat True
Very True
Completely True

I like to be in control *

Not True
Somewhat True
Very True
Completely True

Other (please specify)

Categories of Obsessions: Contamination (germs, etc.) *

Current
Past