SCL-45

Name*

Phone Number

Please enter a valid phone number.

Date*

Date

Email

example@example.com

For each question below select how you have felt during the past week.

0= Not At All 4= Very Much

Do you have pains in your lower back?*

Do you feel blocked in getting things done?*

Do you feel shy or uneasy with the opposite sex?*

Do you feel lonely?*

Do you feel nervous or shaky inside?*

Do you have temper outburst you can't control?*

Are you afraid in open space or on the streets?*

Do you feel that most people cannot be trusted?*

Do you feel the others can control your thoughts?*

Do you experience soreness in you muscles?*

Do you have to check and recheck what you do?*

Are your feelings easily hurt?*

Are you blue?*

Are you suddenly scared for no reason?*

Do you have urges to beat or harm someone?*

Are you afraid to go out of your house alone?*

Do you feel that you are being watched or talked about by others?*

Do you hear voices that other do not hear?*

Do you experience hot or cold spells?*

Do you have difficulty making decisions?*

Do you feel inferior to others?*

Do you worry too much about things?*

Do you feel fearful?*

Do you have urges to smash or break things?*

Are you afraid to travel on buses, subways or trains?*

Do others not give you proper credit for your achievements?*

Do you have thoughts that are not your own?*

Do you experience numbness or tingling in parts or your body?*

Does your mind go blank?*

Do you feel uneasy when people watch or talk about you?*

Do you feel no interest in things?*

Do you feel tense or keyed up?*

Are you uneasy in crowds, such as shopping or at movies?*

Do you feel that people will take advantage of you?*

Do you feel lonely even when you are with people?*

Do you feel weak in parts of your body?*

Do you have trouble concentrating?*

Do you feel very self-conscious when with other people?*

Do you feel hopeless about the future?*

Do you have spells of terror or panic?*

Do you feel that you are being punished for your sins?*

Do you have feeling or heaviness in your arms or legs?*

Do you feel worthless?*

Do you feel so restless you can't sit still?*

Do you feel something is wrong with your mind?*

SCORE

(Add the total of each answer)

0 (How many "0" answers)*

1 (How many "1 " answers)*

2 (How many "2" answers)*

3 (How many "3" answers*

4 (How many "4" answers)*

Select your therapist*