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'L-90-R’ Hond-Scored Answer Sheet nptom Checklist-90-R Tenant. Demat PRD ADMINISTRATOR: BE SURE THE DEMOGRAPHIC INFORMATION ON PAGE 9 15 COMPLETED. AFTER THE QUESTIONNAIRE IS COMPLETED, DETACH PAGE 9 BY CAREFULLY TEARING ALONG THE PERFORATED LINE. THEN DISCARD PAGES 1 THROUGH 8 AS YOU WOULD OTHER CONFIDENTIAL DOCUMENTS PEARSO ip 8 oy, ot a ip ia is pail @Psychcop 151617 18 19 20 21 2223 24A8CDE Product Number 05675, ———— eee INSTRUCTIONS The SCL-90-R test consists of a list of problems people sometimes have. Read each one carefully and circle the number of the response that best describes HOW MUCH THAT PROBLEM HAS DISTRESSED OR BOTHERED YOU DURING THE PAST 7 DAYS INCLUDING TODAY. Circle only one number for each problem (0 1@)3 4). Do not skip any items. If you change your mind, draw an X through your original answer and then circle your new answer (0 1(2{3@). Read the example before you begin. If you have any questions, please ask them now. EXAMPLE O=Notatall 1=Allttlebit © 2=Moderately 3=Quiteabit 4 = Extremely HOW MUCH WERE YOU DISTRESSED BY: Body aches. yencorp san imprint of Pearson Cnc Assesment. aon executive fice 569% Gren Valley Drive Bloomington, MN $5437 Lazo 800.627.7271 www.PearsonClinical.com = wreaes: iat © 1973 2004 Leonard R. Derg PRD. A gh reseed Phe and dtu exes y NES Pearson, inc Warning: No part ofthis publication may be reproduced or transmitted In any f tmechantal,ncusing phokocopy, recording, or any information storaye sad reson fram the copyright owner: Pearson, the PST logo, and PaychCorp are trademarks in the U.S. and/or other court re Is aftat(s), S€L-9O-R i 9 registered trademark cf LeonordR. Derogatis, Po, oeeeS Of Pearson Eaton, I Printed inthe United States of Americ. ™ oF by any means, electronic OF vol system, without permission in wind Pace 2 = Not at all 1=Alittle bit 2= Moderately 3 = Quite abit HOW MUCH WERE YOU DISTRESSED BY: 1. Headaches ° 2. Nervousness or shakiness inside ° 3, Repeated unpleasant thoughts that won't leave your mind ° 4, Faininess or dizziness ° 5, Loss of sexual interest or pleasure... “0 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 tfOUBIES ° 9, Trouble remembering things ° 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 streets 6 414, Feeling low in energy or slowed down ° 15. Thoughts of ending your life 16. Hearing voices that other people do not hear i eon 47. Trembling ° 18. Feeling that most people cannot be trusted wu. ° 19, POOF APE nner ATS 20. Crying easily... Sonne 0 21. Feeling shy or uneasy with the opposite sex ° 22. Feelings of being trapped or caught se anf 23. Suddenly scared for no reason =o 24, Temper outbursts that you could not control seers 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 ...... we 0 28) Feeling lonely 30. Feeling blue .... 0 “Go on to the next page Page 3 o=Notatall 1=Allttlebit 2=Moderately 3=Quiteabit 4 = Extremely HOW MUCH WERE YOU DISTRESSED BY: 31. Worrying too much about things a 7 on 32. Feeling no interest in things 83. Feeling feartul.... 34. Your feelings being easily hurt o1 85, Other people being aware of your private thoughts 04 96, Feeling others do not understand you or are unsympathetic... Zo 97. Feeling that people are untriendly or dislike you 04 38, Having to do things very slowly to insure correctness 04 39, Heart pounding or racing on 40, Nausea or upset stomach 04 41. Feeling inferior to others... o1 42, Soreness of your muscles z 04 43. Feeling that you are watched or talked about by others o 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 acivlies because they tighten you 51. Your mind going blank... '52. Numbness or tingling in parts of your body... 83, Alump 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 feélings in your arms or legs 59. Thoughts of death or dying 180; Overeating Go on to the next page Page 5

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