by Eve Bernstein Carlson, Ph.D. & Frank W. Putnam, M.D.
Directions: This questionnaire consists of twenty eight questions about experiences that you may have in your daily life. We are interested in how often you have these experiences. It is important, however, that your answers show how often these experiences happen to you when you are not under the influence of alcohol or drugs. To answer the questions, please determine to what degree the experience described in the question applies to you and choose the button which corresponds to the percentage of the time you have the experience. The left of the scale, labelled ‘Never’, corresponds to 0% of the time, while the right of the scale, labelled ‘Always’, corresponds to 100% of the time; the range covers 0% to 100% in 10% increments.
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