Instructions: For each item, rate how often you have had that experience over the past month. Enter a number from 0 to 10 in the score box on the right.

Instructions: How often do you have the following experiences when you are not under the influence of alcohol or drugs? Write the number that best describes you. Write 0 if the experience never happens; write 10 if it always happens. Choose a number between 1 and 9 for anything in between.