Dissociative Symptoms WorksheetSeverity of Dissociative Symptoms - Adult Name*Age*Sex:* Male FemaleDate* Date Format: MM slash DD slash YYYY Input a value that best fits you. (0) Not at all, (1) Once or twice, (2) Almost every day, (3) About once a day, (4) More than once a dayI find myself staring into space and thinking of nothing (0) Not at all, (1) Once or twice, (2) Almost every day, (3) About once a day, (4) More than once a day*Please enter a number from 0 to 4.People, objects, or the world around me seem strange or unreal. (0) Not at all, (1) Once or twice, (2) Almost every day, (3) About once a day, (4) More than once a day*Please enter a number from 0 to 4.I find that I did things that I do not remember doing. (0) Not at all, (1) Once or twice, (2) Almost every day, (3) About once a day, (4) More than once a day*Please enter a number from 0 to 4.When I am alone, I talk out loud to myself. (0) Not at all, (1) Once or twice, (2) Almost every day, (3) About once a day, (4) More than once a day*Please enter a number from 0 to 4.I feel as though I were looking at the world through a fog so that people and things seem far away or unclear. (0) Not at all, (1) Once or twice, (2) Almost every day, (3) About once a day, (4) More than once a day*Please enter a number from 0 to 4.I am able to ignore pain. (0) Not at all, (1) Once or twice, (2) Almost every day, (3) About once a day, (4) More than once a day*Please enter a number from 0 to 4.I act so differently from one situation to another that it is almost as if I were two different people. (0) Not at all, (1) Once or twice, (2) Almost every day, (3) About once a day, (4) More than once a day*Please enter a number from 0 to 4.I can do things very easily that would usually be hard for me. (0) Not at all, (1) Once or twice, (2) Almost every day, (3) About once a day, (4) More than once a day*Please enter a number from 0 to 4.Raw Score
