DIAMOND Self Report Screener

Please read the following statements and circle YES or NO to indicate whether each statement applies to
you. If you are not sure whether a statement applies to you, circle YES and ask your interviewer about it.

Interview
page

1. I get very anxious or fearful in social situations or when I am being 7

Yes No
observed.

2. I have had a panic attack, where I experienced a lot of fear and 11

Yes No
physical sensations that came out of the blue.

3. I feel very fearful or anxious in situations where it's difficult to escape

quickly or get help (for example, using public transportation, being in 15
Yes No
open or enclosed spaces, standing in line or being in a crowded place
or being alone away from home).

4. I feel excessively anxious or worried about many things, a lot of the

Yes No time (for example, worry about finances, responsibilities at 19
work/school, my health or the health of others).

5. There are certain objects, situations, or activities that I am very afraid

Yes No of (for example, like animals, insects, blood, needles, heights, storms, 23
flying, choking, vomiting, or enclosed spaces).

Yes No 6. I feel very afraid to be away from a certain person or people. 27

7. I have had a period of four days or more when my mood was so good
Yes No or elevated, like I was on top of the world, that it caused problems for 30
me, or people thought I wasn't my usual self.

8. I have been feeling down, blue, or depressed frequently over the past 34
Yes No
two years.

9. I have had a time when I felt very sad, blue, down, or depressed, or 38
Yes No
lost interest or pleasure in my usual activities, for two weeks or more.

10. (If applicable) I get really depressed, irritable, anxious, or have mood 53
Yes No
swings in the week prior to menstruation (my period).

11. I have frequent thoughts, urges, or images that I don't want to have
Yes No (for example, thoughts about being contaminated even though I may 57
not be, or that I may hurt someone else even though I don’t want to).

12. I do repetitive behaviors (for example, hand washing or cleaning,

Yes No 57
ordering or arranging, checking things, or repeating behaviors over
and over), or I repeatedly do things in my mind (for example,
DIAMOND Self Report Screener v.1.3 © 2022 The Institute of Living/Hartford HealthCare Corporation 1
 counting, saying certain words or phrases) in order to feel better or to
prevent something bad from happening.

Yes No 13. I spend a lot of time worrying about my physical appearance. 61

Yes No 14. My house is excessively cluttered. 64

Yes No 15. I frequently pull out hair from my scalp or my body. 68

Yes No 16. I frequently pick at my skin. 68

17. I have a physical health problem that makes me very worried or 72

Yes No
anxious, or requires me to do a lot to diagnose or monitor it.

18. I often worry that I have a serious medical illness or injury, or that I am 74
Yes No
going to develop a serious medical illness or injury.

19. I am distressed about a really bad event (like seeing something that
was life-threatening or caused someone to die, being seriously injured 77
Yes No
or seeing someone be seriously injured, or being sexually assaulted or
molested) that I have experienced or witnessed.

20. I'm having a hard time dealing with a stressful or unpleasant 85

Yes No
experience, or a major change in my life.

Yes No 21. I avoid eating food because I think I am overweight. 87

22. I often have eating "binges," in which I eat more than most people 90
Yes No
would eat, and it feels like my eating is out of control.

Yes No 23. I eat very little, have difficulty eating enough, or avoid certain foods. 95

24. I have had 3 or more alcoholic drinks within a 3 hour period on 3 or 98

Yes No
more occasions.

25. I have used drugs (including cannabis, even if prescribed), or I have

Yes No used prescription medications other than how they were prescribed, 98
more than three times.

Yes No 26. I have difficulty paying attention or concentrating when I need to. 103

Yes No 27. It often seems that I have difficulty sitting still or waiting for things. 103

28. I have a lot of sudden movements (tics) that are hard to control, or 106
Yes No
make sounds that are hard to control.

DIAMOND Self Report Screener v.1.3 © 2022 The Institute of Living/Hartford HealthCare Corporation 2
 29. I have had very strong beliefs in something that other people thought
were strange, such as any of the following:
a. That people were conspiring against me, spying on me, or
harassing me
b. That a governmental or religious organization was following me or
harassing me
c. That someone I didn’t know, such as a celebrity, was in love with
me
d. That I had special talents or powers, or that I was famous
e. That there was something very strange going on with my body
Yes No 108
f. That someone had removed thoughts from my mind, placed
thoughts in my mind, or read my mind
g. That someone or something was controlling my movements and
actions
h. That someone was sending me special messages through the TV,
radio, or books
i. That I did not exist, that the world did not exist, or that the world
was ending
j. That a partner was being unfaithful to me
k. That I was responsible for a disaster or serious crime and needed
to be punished

30. I have had sensory experiences that others could not understand, such
as:
a. Hearing sounds that others couldn’t hear, such as voices or music
b. Seeing things that others couldn’t see, such as colors, animals,
Yes No people, or spirits 110

c. Having unusual sensations in my body, such as a feeling of electric

shocks or bugs on me
d. Smelling odors that others could not smell, such as vomit, feces,
or something rotting

DIAMOND Self Report Screener v.1.3 © 2022 The Institute of Living/Hartford HealthCare Corporation 3