134
IPDE ICD-10 module screening
questionnaire
Last Name First Name Middle I. Date
Directions
1 The purpose of this questionnaire is t o learn what type of person you have
been during the p a n five years.
2 Please do not skip any items. If you are not sure of an answer, select the one-
TRUE or FALSE-which is more likely t o be correct. There is no time limit,
but do not spend too much time thinking about the answer to any single
statement.
3 When the answer is TRUE, circle the letter T. When the answer is FALSE,
circle the letter F.
135 Screening questionnaire
Iusually get fun and enjoyment out of life.
Idon't react well when someone offends me
I'm not fussy about little details.
Ican't decide what kind of person Iwant to be.
Ishow my feelings for everyone to see.
Ilet others make my big decisions for me.
Iusually feel tenseor nervous.
Ialmost never get angry about anything.
Igo to extremes t o try t o keep people from leaving me.
I'm a very cautious person.
I've never been arrested.
People think I'm cold and detached.
Iget intovery intense relationshipsthat don't last.
Most people are fair and honest with me.
Ifind it hard to disagree with people if Idepend on them a lot.
Ifeel awkwardor out of place in srxial situations.
I'm too easily influenced by what goes on around me.
Iusually feel bad when I hurt or mistreat someone.
Iargue or fightwhen peopletry to stop me from doing what I want.
At times I've refusedt o hold a job, even when Iwas expected to.
When I'm praised or criticized Idon't show others my reaction.
I've held grudges against people for years.
Ispend too much time trying to do things perfectly.
People often make fun of me behind my back.
I've never threatened suicide or injured myself on purpose.
My feelings are like the weather; they'realways changing.
Ifight for my rights even when it annoys people.
I like to dressso Istand out in a crowd.
I will lie or con someone H it serves my purpose.
I don't stick wlth a plan if I don't get results right away.
I have little or no desire to have sex with anyone.
People think I'm toostrict about rules and regulations.
Iusuallyfeel uncomfortableor helplesswhen I'm alone.
Iwon't get involvedwith people until I'm certain they like me.
I would rather not be the centre of attention.
Ithink my spouse (or lover) may be unfaithful to me.
Sometimes I get m angry Ibreak or smash things.
I've had close friendshipsthat lasted a long time.
Iworrya lot that people may not like me.
i often feel "empty" inside.
Iwork m hard Idon't have time left for anything else.
Iworry about being left alone and having to care for myself.
A lot of thingsseem dangerousto me that don't bother most people.
Ihave a reputation for being aflirt.
I don't ask favorsfrom people Idepend on a lot.
I prefer activities that Ican do by myself.
136 Screening questionnaire
47 1 lose my temper and get into physical fights. T F
48 People think I'm too stiff or formal. T F
49 1 often seek advice or reassurance about everyday decisions. T F
50 1 keep to myself even when there are other people around. T F
51 It's hard for me to stay out of trouble. T F
52 I'm convinced there's a conspiracy behind many things in the world. T F
53 I'm very moody. T F
54 R's hard for me to get used to a new way of doing things. T F
55 Most peoplethink I'm a strange person. T F
56 1 take chances and do recklersthings. T F
57 Everyone needs a friend or two to be happy. T F
58 I'm more interestedin my own thoughts than what goeson around me. T F
59 1 usually trytoget people to do things my way. T F
