The questions below refer to times when you have not been using alcohol or pleasure drugs.

There are two columns marked C and P. You will be writing a number into both of them which will allow us to know how often the symptom or event has happened to you. The left column under P refers to the greatest frequency in the past (ie: frequency at which it occurred at its worst); the column under C refers to your current experience (how often it has happened recently - today, this week, month, or year-if rare).

0=never, 1=less than once per year, 2=yearly or more, 3=monthly or more, 4=weekly or more, 5=daily, 6=more than daily.

Indicate how often the event occurs by writing the frequency number into columns P and C. So if the symptom has never happened, you will write in 0 under Cand P. If another symptom has been happening currently every day, you would fill in 5 under C. Let's imagine an example to make things clearer - Mr. Smith answered question #24 like this:

4 0 24) How often does time seem to be (x)speeded up or ( )slowed down or (x)not existing for periods (x)of minutes, ( )up to several hours?

He did so because: He remembers that in the past when the symptom was at its worst, time seemed to speed up for minutes every week (=4). However, it does not happen currently (=0). He writes the most frequent number under each column. (i.e. #4 for past, under P and zero (0) for current, under C). Even though it does not currently happen, he still fills in the 0 because otherwise his physicians may think he just ignored the question. He wants to let his physicians know that time was speeded up, that it lasted for minutes, and that there was also a sense of timelessness, so he checked each of those brackets. Also, in the past time was speeded up weekly (=4) while time was not existing yearly(=2). He wrote "4" under P because it was the most frequent number for this symptom in the past (i.e. weekly (=4) more frequent than yearly (=2).


P C remember C is currently happening to you, P is any time in the past but not the current time
    1) How often do you have episodes of ( )fits, ( )seizures or ( )"peculiar spells"?
    2) How often have you had a blackout or lost consciousness for a short time like seconds or minutes? Do not include times when you were knocked unconscious or fainted.
    3) How often have you or are you told that: you at times lose contact with ( )staring spells or ( )episodes where you have a blank look on your face ( ( )for seconds or ( )minutes? )
    4) How often do you find that you suddenly feel confused or perplexed (you don't know where you are, or why you are there, or what time or date it is) and then have the feeling pass in a few minutes?
    5) How often have you for a very short time like seconds or minutes been completely unaware that you did or been told that you did any of the following: ( )odd behaviors like ( )buttoning/unbuttoning; ( )chewing/mouth movements or ( )other unusual movements or ( )doing very strange things or ( )saying strange things or ( )finding yourself in places you don't remember going to?
    6) How often do your ( )moods, ( )feelings or ( )thoughts fluctuate within minutes for no reason (like ( ) very happy then very sad)?
    7) How often do you... ( )have clear cut gaps in your memory during which you cannot remember anything for 5 minutes or more; ( )miss major sections of TV shows you have been watching; ( )find yourself driving without remembering how you got there or where you are going; ( )do strange things automatically?
    8) How often have you... ( )lost control of yourself due to anger; ( )easily become very irritable over 'nothing'; ( )become extremely angry; ( )got into an extremely bad temper; ( )been told by others about an anger episode of yours that you do not remember; ( )been told that you become violent or aggressive and you have no recollection of this?
    9) How often do you have a ( )strange sensation or ( )pain in your stomach, belly or upper abdomen not related to eating?
    10) How often have you come across a smell when there is nothing to cause it? ( If so, what kind (check applicable)? ( )medicine; ( )steak; ( )perfume; ( )flowers; ( )burning; ( )rotting; ( )synthetic; ( )vomit; ( )incense; ( )musty; ( )grass; ( )bitter; ( )sweet; ( )cake; ( )mustard; ( )other____________ )
    11) How often have you seen any of the following? Check all applicable. ( )dots; ( )lights; ( )patterns; ( )shapes; ( )wrong size; ( )movements; ( )distorted; ( )things moving; ( )stars; ( )bugs; ( )threads; ( )insects;; ( )other_______________________________________ (Were these in front of your eyes or in your side vision or both? ( )front vision; ( )side vision; ( )both)
    12) How often do you encounter tastes in your mouth which you cannot explain? (If so, what quality? ( )metallic; ( )bitter; ( )salt; ( )sweet; ( )sour; ( )other_______________________________________)
    13) How often do you hear any of the following, when there is no-one or nothing to cause it? Check all applicable. ( )buzz; ( )ring; ( )sizz; ( )hiss; ( )tap; ( )songs; ( )whistling; ( )music; ( )single word; ( )arguing; ( )names; ( )voices; ( )jumble; ( )message; ( )instructing; ( )radio/TV; ( )phone; ( )other _________________________________________
    14) How often do you have odd sensations in part of your body like ( )floating, ( )turning or ( )moving when you were doing none of those?
    15) How often do you have episodes of sudden, unexplained dizziness?
    16) How often do you feel strange sensations or crawling in your skin without reason?

( )insects; ( )other______________________________

    17) How often have you been in a familiar place and had the impression that you have never been in that place before? (the opposite of déjà vu called jamais vu - not recognized at all, totally unfamiliar)
    18) How often do you find familiar persons or places: ( )strange, ( )foreign, or ( )different?
    19) How often have you had déjà vu: You have ( ) gone somewhere, ( ) met someone, ( ) heard words, ( ) thought something, or ( ) said something, for the first time and felt it was familiar - as if you had been through it before?
    20) How often have you found that, for no apparent reason, you are actually reliving things in the past (as if the past flows like a movie screen before you)?
    21) How often do you have an overwhelming feeling that things are ( )weird, or ( )wrong, or ( )distorted?
    22) How often do you feel you ( )are not yourself, or ( )are just watching yourself, or ( )are not part of yourself?
    23) How often have you felt possessed by some kind of being or alien or something not yourself?
    24) How often do you feel someone is ( )watching, ( )observing or ( )plotting specifically against you?
    25) How often does time seem to be ( )speeded up or ( )slowed down or ( )not existing for periods ( )of minutes, ( )up to several hours?
    26) How often do you have sudden, unexplained or uncontrollable attacks of intense fear for no apparent reason?
    27) How often have you ( )had episodes of intense religious feeling, for example ( )you felt at one with the world or ( )felt that in some special way God had touched or had spoken to you or ( )felt as though you were close to a powerful spiritual life force?
    28) How often have you had repeated and unreasonable thoughts that you cannot stop from thinking even though you try - they keep coming into your mind?
    29) How often have you had episodes of compulsive sexual behavior that was out of character for you?
    30) How often have you had episodes of ( )compulsive eating (binge eating with or without vomiting) of such intensity that you felt out of control and could not stop or of ( )deliberate (not religious) starving of yourself?
    31) How often do you write the events in your life in detail down in a diary?
    32) How often do you hear what is being said, yet you cannot understand or make sense of it?
    33) How often do you discover that: ( )
    34) How often do you find that you are ( )slurring your speech or ( )cannot talk, when not due to alcohol or other drugs?
    35) How often do you have difficulty concentrating? (Has it become worse every year? ( )yes; ( )no)
    36) How often do you feel ( )depressed or ( )anxious or ( )tense ?
    37) How often do you have severe headaches? (If so : Do you get ( )nauseous or/and ( )see stars /funny /blurred with them? ( )most times / ( )rarely )
    38) How often do you get a ( )pain or ( ) sensation in your head which you would not classify as a "headache"?
    39) How often do you have double vision?
    40) How often do you ( )get very tired even when you had enough sleep or ( )sleep so soundly during the day that no one can arouse you?
    41) How often do you snore ( )so loudly or ( )for so long that others notice?
    42) How often do you ( )wake three or more times in the night or ( )lie awake three or more hours trying to sleep?
    43) How often do you dream?
    44) How often do you have exactly the same repetitive dream and/or frightening nightmares?
    45) How often have you had "psychic", intuitive or paranormal experiences which prove correct?
    46) How often have you ( )seen events that happened at a great distance as they were happening or ( )felt as though you were in touch with someone when they were far away from you?
    47) How often have you felt you have left your body?
    48) How often have you been close to death and been aware of a strange experience? (If so, was it like you had died and come back (so-called near-death experiences)
49) Do you find there are any specific things which trigger any one of the symptoms/ experiences discussed (e.g. ( )lights flashing or a sudden or special ( )sound, ( )smell)? ( )yes; ( )no. If yes, which ones (give the item numbers from above questions)? Numbers: _____________________________________________
50) Which symptoms began only after a head injury or other problem like encephalitis, meningitis or a car accident? Please list (give the item numbers from above questions). Numbers: ___________________________



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