2024年2月25日发(作者：贡海)
Psychiatric University Hospital Zurich, P.O. Box 1931, CH-8032 Zurich, Switzerland
27.12.2007
Psychiatric University Hospital Zurich, Division of Clinical Psychiatry
SYMPTOM CHECK LIST
L.R. Derogatis, R.S. Lipman,
STUDY
GROUP
PATIENT
RATING DAY
CARD NUMBER
Sex (1=male, 2=female)
S C L 90
[ _ _ _ _ ]
[ _ _ ]
[ _ _ _ ]
[ _ _ _ ]
[ _ _ ]
[ _ ]
[ _ _ : _ _ : _ _ ]
[ _ _ : _ _ :
_
_
]
[ _ _ _ . _ _ ]
[ _ _ _ . _ _ ]
[ _ ]
[ _ _ ]
[ _ ]
[ _ _ _ ]
[ _ ]
[ _ _ _ ]
[ _ ]
[ _ _ : _ _ : _ _ ]
[ _ _ _ ]
[ _ _ ]
[ _ _ _ _ _ _ _ _ _ _ _ _ ]
1-4
5-6
7-9
10-12
13-14
15
16-21
22-27
28-32
33-37
38
39-40
41
42-44
45
46-48
49
50-55
56-58
59-60
61-72
Birthday ()
Date of hospitalization ()
First diagnosis
Second diagnosis
Diagnostic system (1=ICD9, 2=ICD10, 3=DSM3-R, 4=DSM4)
Age at onset
Course (1=first manifestation, 2=intermittent, 3=progredient, 4=chronic)
Duration of Current Episode Prior to Hospitalization (days)
Medication Prior to Hospitalization (0=none, 1=antidepr., 2=neuroleptics, 3=other)
Current Medication (cf. list of codes)
Educational level (1=remedial, 2=junior high, 3=high, 4=college)
DATE ()
INTERVIEWER
HOSPITAL
PATIENT ID (the hospital’s internal PID)
©
2004
Psychiatric University Hospital Zurich, P.O. Box 1931, CH-8032 Zurich, Switzerland
27.12.2007
Attached is a list of problems and complaints that people have. Please read each one carefully.
After you have done so, please fill in the number (0 to 4, see below) which best describes how
much that problem has bothered or distressed you during the past 4 weeks including
today. Choose only one number for each problem and do not skip any items. If you change
your mind, erase your first answer and fill in the new one. All questionnaires will be treated
confidentially!
0 = not at all; 1 = a little bit; 2 = moderately; 3 = quite a bit; 4 = extremely;
Please fill in the appropriate number within the brackets!
1-12 dupl
Card number
[ _ _ ] 13-14
[ _ ] 15
[ _ ] 16
[ _ ] 17
[ _ ] 18
[ _ ] 19
[ _ ]
20
How much were you bothered or distressed over the past 4 weeks by
1
Headaches
2
Nervousness or shakiness inside
3
Unwanted thoughts or ideas that won’t leave your head
4 Faintness or dizziness
5 Loss of sexual interest or pleasure
6 Feeling critical of others
7 The idea that someone else can control your thoughts
8 Feeling others are to blame for most of your troubles
9 Trouble remembering things
[ _ ] 21
[ _ ] 22
[ _ ] 23
[ _ ] 24
[ _ ] 25
[ _ ] 26
[ _ ] 27
[ _ ] 28
[ _ ] 29
[ _ ] 30
[ _ ] 31
[ _ ] 32
[ _ ] 33
[ _ ] 34
[ _ ] 35
[ _ ] 36
[ _ ] 37
[ _ ] 38
10
Worried about sloppiness or carelessness
11 Feeling easily annoyed or irritated
12 Pains in heart or chest
13
Feeling afraid in open spaces or on the street
14 Feeling low in energy or slowed down
15 Thoughts of ending life
16 Hearing voices that other people do not hear
17 Trembling
18 Feeling that most people cannot be trusted
19 Poor appetite
20 Crying easily
21 Feeling shy or uneasy with the opposit sex
22 Feeling of being trapped or caught
23 Suddenly scared for no reason
24 Temper outbursts that you could not control
2
Psychiatric University Hospital Zurich, P.O. Box 1931, CH-8032 Zurich, Switzerland
25 Feeling afraid to go out of your house alone
26 Blaming yourself for things
27
Pains in lower back
28 Feeling blocked in getting things done
29
Feeling lonely
30
Feeling blue
31
Worrying too much about things
32
Feeling no interest in things
33 Feeling fearful
34
Your feelings being easily hurt
35
Other people being aware of your private thoughts
36
Feeling others do not understand you or are unsympathetic
37
Feeling that people are unfriendly
38
Having to do things very slowly
39
Heart pounding or racing
40 Nausea or upset stomach
41
Feeling inferior to others
42 Soreness of your muscles
43
Feeling that you are watched or talked about by others
44
Trouble falling asleep
45 Having to check and double check what you do
46 Difficulty making decisions
47 Feeling afraid to travel on buses, subways or trains
48 Trouble getting your breath
49 Hot or cold spells
50 Having to avoid certain things, places or activities
51 Your mind going blank
52 Numbness or tingling in parts of your body
53 A lump in your throat
54 Feeling hopeless about the future
55
Trouble concentrating
56
Feeling weak in parts of your body
57
Feeling tense or keyed up
58
Heavy feelings in your arms or legs
27.12.2007
[ _ ] 39
[ _ ] 40
[ _ ] 41
[ _ ] 42
[ _ ] 43
[ _ ] 44
[ _ ] 45
[ _ ] 46
[ _ ] 47
[ _ ] 48
[ _ ] 49
[ _ ] 50
[ _ ] 51
[ _ ] 52
[ _ ] 53
[ _ ] 54
[ _ ] 55
[ _ ] 56
[ _ ] 57
[ _ ] 58
[ _ ] 59
[ _ ] 60
[ _ ] 61
[ _ ] 62
[ _ ] 63
[ _ ] 64
[ _ ] 65
[ _ ] 66
[ _ ] 67
[ _ ] 68
[ _ ] 69
[ _ ] 70
[ _ ] 71
[ _ ] 72
3
Psychiatric University Hospital Zurich, P.O. Box 1931, CH-8032 Zurich, Switzerland
Card number
59
Thoughts of death or dying
60
Overeating
61
Feeling uneasy when people are watching or talking about you
62
Having thoughts that are not your own
63
Having urges to beat, injure or harm someone
64
Awakening in the early morning
65
Having to repeat the same actions such as touching, counting, washing
66
Sleep that is restless or disturbed
67
Having urges to break or smash things
68
Having ideas or beliefs that others do not share
69
Feeling very self-conscious with others
70
Feeling uneasy in crowds such as shopping or at a movie
71
Feeling everything is an effort
72
Spells of terror or panic
73
Feeling uncomfortable about eating or drinking in public
74
Getting into frequent arguments
75 Feeling nervous when you are left alone
76 Others not giving you proper credit for your achievments
77 Feeling lonely even when you are with people
78 Feeling so restless you couldn’t sit still
79 Feeling of worthlessness
80 Feeling that familiar things are strange or unreal
81 Shouting or throwing things
82 Feeling afraid you will faint in public
83 Feeling that people will take advantage of you if you let them
84 Having thoughts about sex that bother you a lot
85 The idea that you should be punished for your sins
86 Feeling pushed to get things done
87 The idea that something serious is wrong with your body
88 Never feeling close to another PERSONAL
89 Feelings of guilt
90 The idea that something is wrong with your mind
Please go back and check that you have answered all questions.
4
27.12.2007
1-12 dupl
[ _ _ ] 13-14
[ _ ] 15
[ _ ] 16
[ _ ] 17
[ _ ] 18
[ _ ] 19
[ _ ] 20
[ _ ] 21
[ _ ] 22
[ _ ] 23
[ _ ] 24
[ _ ] 25
[ _ ] 26
[ _ ] 27
[ _ ] 28
[ _ ] 29
[ _ ] 30
[ _ ] 31
[ _ ] 32
[ _ ] 33
[ _ ] 34
[ _ ] 35
[ _ ] 36
[ _ ] 37
[ _ ] 38
[ _ ] 39
[ _ ] 40
[ _ ] 41
[ _ ] 42
[ _ ] 43
[ _ ] 44
[ _ ] 45
[ _ ] 46
2024年2月25日发(作者：贡海)
Psychiatric University Hospital Zurich, P.O. Box 1931, CH-8032 Zurich, Switzerland
27.12.2007
Psychiatric University Hospital Zurich, Division of Clinical Psychiatry
SYMPTOM CHECK LIST
L.R. Derogatis, R.S. Lipman,
STUDY
GROUP
PATIENT
RATING DAY
CARD NUMBER
Sex (1=male, 2=female)
S C L 90
[ _ _ _ _ ]
[ _ _ ]
[ _ _ _ ]
[ _ _ _ ]
[ _ _ ]
[ _ ]
[ _ _ : _ _ : _ _ ]
[ _ _ : _ _ :
_
_
]
[ _ _ _ . _ _ ]
[ _ _ _ . _ _ ]
[ _ ]
[ _ _ ]
[ _ ]
[ _ _ _ ]
[ _ ]
[ _ _ _ ]
[ _ ]
[ _ _ : _ _ : _ _ ]
[ _ _ _ ]
[ _ _ ]
[ _ _ _ _ _ _ _ _ _ _ _ _ ]
1-4
5-6
7-9
10-12
13-14
15
16-21
22-27
28-32
33-37
38
39-40
41
42-44
45
46-48
49
50-55
56-58
59-60
61-72
Birthday ()
Date of hospitalization ()
First diagnosis
Second diagnosis
Diagnostic system (1=ICD9, 2=ICD10, 3=DSM3-R, 4=DSM4)
Age at onset
Course (1=first manifestation, 2=intermittent, 3=progredient, 4=chronic)
Duration of Current Episode Prior to Hospitalization (days)
Medication Prior to Hospitalization (0=none, 1=antidepr., 2=neuroleptics, 3=other)
Current Medication (cf. list of codes)
Educational level (1=remedial, 2=junior high, 3=high, 4=college)
DATE ()
INTERVIEWER
HOSPITAL
PATIENT ID (the hospital’s internal PID)
©
2004
Psychiatric University Hospital Zurich, P.O. Box 1931, CH-8032 Zurich, Switzerland
27.12.2007
Attached is a list of problems and complaints that people have. Please read each one carefully.
After you have done so, please fill in the number (0 to 4, see below) which best describes how
much that problem has bothered or distressed you during the past 4 weeks including
today. Choose only one number for each problem and do not skip any items. If you change
your mind, erase your first answer and fill in the new one. All questionnaires will be treated
confidentially!
0 = not at all; 1 = a little bit; 2 = moderately; 3 = quite a bit; 4 = extremely;
Please fill in the appropriate number within the brackets!
1-12 dupl
Card number
[ _ _ ] 13-14
[ _ ] 15
[ _ ] 16
[ _ ] 17
[ _ ] 18
[ _ ] 19
[ _ ]
20
How much were you bothered or distressed over the past 4 weeks by
1
Headaches
2
Nervousness or shakiness inside
3
Unwanted thoughts or ideas that won’t leave your head
4 Faintness or dizziness
5 Loss of sexual interest or pleasure
6 Feeling critical of others
7 The idea that someone else can control your thoughts
8 Feeling others are to blame for most of your troubles
9 Trouble remembering things
[ _ ] 21
[ _ ] 22
[ _ ] 23
[ _ ] 24
[ _ ] 25
[ _ ] 26
[ _ ] 27
[ _ ] 28
[ _ ] 29
[ _ ] 30
[ _ ] 31
[ _ ] 32
[ _ ] 33
[ _ ] 34
[ _ ] 35
[ _ ] 36
[ _ ] 37
[ _ ] 38
10
Worried about sloppiness or carelessness
11 Feeling easily annoyed or irritated
12 Pains in heart or chest
13
Feeling afraid in open spaces or on the street
14 Feeling low in energy or slowed down
15 Thoughts of ending life
16 Hearing voices that other people do not hear
17 Trembling
18 Feeling that most people cannot be trusted
19 Poor appetite
20 Crying easily
21 Feeling shy or uneasy with the opposit sex
22 Feeling of being trapped or caught
23 Suddenly scared for no reason
24 Temper outbursts that you could not control
2
Psychiatric University Hospital Zurich, P.O. Box 1931, CH-8032 Zurich, Switzerland
25 Feeling afraid to go out of your house alone
26 Blaming yourself for things
27
Pains in lower back
28 Feeling blocked in getting things done
29
Feeling lonely
30
Feeling blue
31
Worrying too much about things
32
Feeling no interest in things
33 Feeling fearful
34
Your feelings being easily hurt
35
Other people being aware of your private thoughts
36
Feeling others do not understand you or are unsympathetic
37
Feeling that people are unfriendly
38
Having to do things very slowly
39
Heart pounding or racing
40 Nausea or upset stomach
41
Feeling inferior to others
42 Soreness of your muscles
43
Feeling that you are watched or talked about by others
44
Trouble falling asleep
45 Having to check and double check what you do
46 Difficulty making decisions
47 Feeling afraid to travel on buses, subways or trains
48 Trouble getting your breath
49 Hot or cold spells
50 Having to avoid certain things, places or activities
51 Your mind going blank
52 Numbness or tingling in parts of your body
53 A lump in your throat
54 Feeling hopeless about the future
55
Trouble concentrating
56
Feeling weak in parts of your body
57
Feeling tense or keyed up
58
Heavy feelings in your arms or legs
27.12.2007
[ _ ] 39
[ _ ] 40
[ _ ] 41
[ _ ] 42
[ _ ] 43
[ _ ] 44
[ _ ] 45
[ _ ] 46
[ _ ] 47
[ _ ] 48
[ _ ] 49
[ _ ] 50
[ _ ] 51
[ _ ] 52
[ _ ] 53
[ _ ] 54
[ _ ] 55
[ _ ] 56
[ _ ] 57
[ _ ] 58
[ _ ] 59
[ _ ] 60
[ _ ] 61
[ _ ] 62
[ _ ] 63
[ _ ] 64
[ _ ] 65
[ _ ] 66
[ _ ] 67
[ _ ] 68
[ _ ] 69
[ _ ] 70
[ _ ] 71
[ _ ] 72
3
Psychiatric University Hospital Zurich, P.O. Box 1931, CH-8032 Zurich, Switzerland
Card number
59
Thoughts of death or dying
60
Overeating
61
Feeling uneasy when people are watching or talking about you
62
Having thoughts that are not your own
63
Having urges to beat, injure or harm someone
64
Awakening in the early morning
65
Having to repeat the same actions such as touching, counting, washing
66
Sleep that is restless or disturbed
67
Having urges to break or smash things
68
Having ideas or beliefs that others do not share
69
Feeling very self-conscious with others
70
Feeling uneasy in crowds such as shopping or at a movie
71
Feeling everything is an effort
72
Spells of terror or panic
73
Feeling uncomfortable about eating or drinking in public
74
Getting into frequent arguments
75 Feeling nervous when you are left alone
76 Others not giving you proper credit for your achievments
77 Feeling lonely even when you are with people
78 Feeling so restless you couldn’t sit still
79 Feeling of worthlessness
80 Feeling that familiar things are strange or unreal
81 Shouting or throwing things
82 Feeling afraid you will faint in public
83 Feeling that people will take advantage of you if you let them
84 Having thoughts about sex that bother you a lot
85 The idea that you should be punished for your sins
86 Feeling pushed to get things done
87 The idea that something serious is wrong with your body
88 Never feeling close to another PERSONAL
89 Feelings of guilt
90 The idea that something is wrong with your mind
Please go back and check that you have answered all questions.
4
27.12.2007
1-12 dupl
[ _ _ ] 13-14
[ _ ] 15
[ _ ] 16
[ _ ] 17
[ _ ] 18
[ _ ] 19
[ _ ] 20
[ _ ] 21
[ _ ] 22
[ _ ] 23
[ _ ] 24
[ _ ] 25
[ _ ] 26
[ _ ] 27
[ _ ] 28
[ _ ] 29
[ _ ] 30
[ _ ] 31
[ _ ] 32
[ _ ] 33
[ _ ] 34
[ _ ] 35
[ _ ] 36
[ _ ] 37
[ _ ] 38
[ _ ] 39
[ _ ] 40
[ _ ] 41
[ _ ] 42
[ _ ] 43
[ _ ] 44
[ _ ] 45
[ _ ] 46