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1/50 In the past 6 months, I have ______ experienced feelings of emptiness.
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2/50 In the past 6 months, I have ______ experienced feelings of worthlessness.
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3/50 In the past 6 months, I have gained/lost a significant amount of weight.
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4/50 I am comfortable with my body.
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5/50 I am confident in my physical appearance.
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6/50 I believe I am a good person.
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7/50 I feel guilty ______.
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8/50 Within the past 6 months, I have lost interest in activities I used to enjoy.
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9/50 I don’t feel comfortable eating a food item if I don’t know how many calories are in it.
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10/50 I hear voices or sounds that other people cannot hear.
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11/50 I see things that other people cannot see.
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12/50 Within the past 6 months, I have had thoughts of hurting myself.
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13/50 Within the past 6 months, I have intentionally hurt myself (cutting, scratching, burning, etc.) ______ times.
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14/50 I worry a lot.
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15/50 I have experienced 4 or more of the following symptoms during a panic attack in the past 6 months: heart racing, sweating, crying, nausea, stomach pain, chest pain, shaking.
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16/50 While feeling out of control, I eat an excessive amount of food until I am uncomfortably full ______.
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17/50 I have experienced a traumatic event.
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18/50 I have panic attacks due to this event.
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19/50 WIthin the past 6 months, I have had nightmares ______.
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20/50 I find it easy to get to sleep.
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21/50 I sleep too much or too little.
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22/50 I throw up my food after I eat it.
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23/50 I feel numb.
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24/50 I feel as though things are not real.
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25/50 I feel as thought my surroundings look 2D or fake.
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26/50 I feel as though my body is not my own, or as thought my mind and body are disconnected from each other.
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27/50 I feel as though I am living in a dream.
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28/50 I experience periods of extreme highs (lasting one week or longer) followed by periods of extreme lows (lasting one week or longer).
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29/50 I feel as though I would be better off dead.
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30/50 I have thoughts of killing myself.
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31/50 I obsessively count things.
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32/50 I experience torturous “intrusive” or “unwanted” thoughts.
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33/50 I become upset if things are not the way I like them.
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34/50 I push people away because I am afraid they will leave me either way.
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35/50 I often feel fidgety or restless.
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36/50 I have rituals that I need to go through with in order to feel satisfied.
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37/50 I can be impulsive.
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38/50 I feel fatigued.
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39/50 I am better than other people.
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40/50 I care about the feelings of other people.
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41/50 I feel as thought people are watching me when I’m alone.
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42/50 I love someone one second, then I suddenly feel as thought I hate them. Then I love them again, then I hate them again. I experience strong conflicting feelings towards people.
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43/50 I enjoy my life.
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44/50 I have difficulty concentrating.
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45/50 I can not control my anger.
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46/50 In the past 6 months, I have experienced a period of complete memory loss. Example: I found myself somewhere and could not recall how I ended up there.
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47/50 Within the past 6 months, I have had multiple “alters” (separate personalities) that present themselves at different times.
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48/50 I become very nervous in social situations.
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49/50 I wish I was dead.
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50/50 There is no hope left for me.
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