Table of Contents
Instructions:
This questionnaire can be completed by the child/adolescent, parents, or both working together. We are interested in getting the most accurate information possible. There are no right or wrong answers. Please just answer the best you can.
| Current | |
| Please check all COMPULSIVE SYMPTOMS that you have noticed during the past week. COMPULSIONS are things you feel compelled to do even though you may know the behaviour does not make sense. Compulsions are typically done to reduce fear of distress associated with obsessive thoughts.
— Washing/Cleaning Compulsions — Excessive or ritualized hand washing (e.g., takes long time to wash, needs to restart if interrupted, needs to wash hands in particular order of steps) |
1 |
| Excessive or ritualized showering, bathing, tooth brushing, grooming, toilet routine | 1 |
| Excessive cleaning of items (e.g., clothes, faucets, floors or important objects) | 1 |
| Other measures to prevent or remove contact with contaminants (e.g., using towel or foot to flush toilet or open door; refusing to shake hands; asking family members to remove insecticides, garbage) | 1 |
| Other washing/cleaning compulsions (Describe) | |
| — Checking Compulsions —
Checking locks, toys, schoolbooks/items, and so on |
1 |
| Checking associated with getting washed, dressed, or undressed | 1 |
| Checking that did not/will not harm others (e.g., checking that nobody’s been hurt, asking for reassurance, or telephoning to make sure that everything is alright) | 1 |
| Current | |
| Checking that did not/will not harm self (e.g., looking for injuries or bleeding after handling sharp or breakable objects, asking for reassurance that everything is alright) | 1 |
| Checking that nothing terrible did/will happen (e.g., searching the newspaper or television for news about catastrophes) | 1 |
| Checking that did not make a mistake (e.g., while reading, writing, doing simple calculations, homework) | 1 |
| Checking tied to health worries (e.g., seeking reassurance about having an illness, repeatedly measuring pulse, checking for body odors or ugly features) | 1 |
| Other checking compulsions (Describe) | |
| — Repeating Compulsions —
Rereading, erasing, or rewriting (e.g., taking hours to read a few pages or write a few sentences because of concern over not understanding or needing letters to be perfect) |
1 |
| Needing to repeat routine activities (e.g., getting up and down from a chair or going in and out of a doorway, turning the light switch or TV on and off a specific number of times) | 1 |
| Other repeating compulsions (Describe) | |
| — Counting Compulsions —
Counts objects (e.g., floor tiles, CDs or books on a shelf, his/her own steps, or words read or spoken) |
1 |
| — Arranging/Symmetry —
Arranging/ordering (e.g., spends hours straightening paper and pens on a desktop or books in a bookcase, becomes very upset if order is disturbed) |
1 |
| Current | |
| Symmetry/evening up (e.g., arranges things or own self so that two or more sides are “even” or symmetrical) | 1 |
| Other arranging compulsions (Describe) | |
| — Hoarding/Saving Compulsion —
Difficulty throwing things away; saving bits of paper, string, old newspapers, notes, cans, paper towels, wrappers and empty bottles; may pick up useless objects from street or garbage |
1 |
| Other hoarding/saving compulsions (Describe) | |
| — Excessive Games/Superstitious Behaviours —
Behaviours such as not stepping on cracks or lines on floor/sidewalk, touching an object/self a certain number to times to avoid something bad happening, not leaving home on the 13th of the month) |
1 |
| — Rituals Involving Other Persons —
Needing to involve another person (usually a parent) in rituals (e.g., excessive asking for reassurance, repeatedly asking parent to answer the same question, making parent wash excessively) |
1 |
| — Miscellaneous Compulsions —
Excessive telling, asking, or confessing (e.g., confessing repeatedly for minor or imagined transgressions, asking for reassurance) |
1 |
| Measures (not checking) to prevent harm to self or others or some other terrible consequences (e.g., avoids sharp or breakable objects, knives, or scissors) | 1 |
| Ritualized eating behaviours (e.g., arranging food, knife, fork in a particular order before eating; eating according to a strict ritual) | 1 |
| Excessive touching, tapping, rubbing (e.g., repeatedly touching particular surfaces, objects, or other people, perhaps to prevent a bad occurrence) | 1 |
| Current | |
| Excessive list making | 1 |
| Needing to do things (e.g., touch or arrange) until it feels “just right” | 1 |
| Avoiding saying certain words (e.g., goodnight or goodbye, person’s name, bad event) | 1 |
| Other compulsions (Describe) | |
| Please check all OBSESSIVE SYMPTOMS that you have noticed during the past week. OBSESSIONS are intrusive, recurrent, and distressing thoughts, sensations, urges, or images that you may experience. They are typically frightening and may be either realistic or unrealistic in nature.
— Contamination Obsessions — Excessive concern with dirt, germs, certain illnesses (e.g., from door handles, other people) |
1 |
| Excessive concern/disgust with bodily waste or secretions (e.g., urine, feces, semen, sweat) | 1 |
| Excessive concern with environmental contaminants (e.g., asbestos or radioactive substances) | 1 |
| Excessive concern with contamination from household items (e.g., cleaners, solvents) | 1 |
| Excessive concern about contamination from touching animals/insects | 1 |
| Excessively bothered by sticky substances or residues (e.g., adhesive tape, syrup) | 1 |
| Current | |
| Concerned will get ill as a result of being contaminated by something (e.g., germs, animals, cleaners) | 1 |
| Concerned will get others ill by spreading contaminant | 1 |
| Other washing/cleaning obsessions (Describe) | |
| — Aggressive Obsessions —
Fear might harm self (e.g., using knives or other sharp objects) |
1 |
| Fear might harm others (e.g., fear of pushing someone in front of a train, hurting someone’s feelings, causing harm by giving wrong advice) | 1 |
| Fear something bad will happen to self | 1 |
| Fear something bad will happen to others | 1 |
| Violent or horrific images (e.g., images of murders, dismembered bodies, other disgusting images) | 1 |
| Fear of blurting out obscenities or insults (e.g., in public situations like church, school) | 1 |
| Fear will act on unwanted impulses (e.g., punch or stab a friend, drive a car into a tree) | 1 |
| Current | |
| Fear will steal things against his or her will (e.g., accidentally “cheating” cashier or shoplifting something) | 1 |
| Fear will be responsible for terrible event (e.g., fire or burglary because didn’t check locks) | 1 |
| Other aggressive obsessions (Describe) | |
| — Hoarding/Saving Obsessions —
Worries about throwing away unimportant things because he or she might need them in the future, urges to pick up and collect useless things |
1 |
| — Health-Related Obsessions —
Excessive concern with illness or disease (e.g., worries that he or she might have an illness like cancer, heart disease, or AIDS despite reassurance from doctors; concerns about vomiting) |
1 |
| Excessive concern with body part or aspect of appearance (e.g., worries that his or her face, ears, nose, arms, legs, or other body part is disgusting or ugly) | 1 |
| Other health-related obsessions (Describe) | |
| — Religious/Moral Obsessions —
Overly concerned with offending God or other religious objects (e.g., having blasphemous thoughts, saying blasphemous things, or being punished for these things) |
1 |
| Excessive concern with right/wrong, morality (e.g., worries about always doing “the right thing,” worries about having told a lie or having cheated someone) | 1 |
| Other religious obsessions (Describe) | |
| Current | |
| — Magical Obsessions —
Has lucky/unlucky numbers, colors, words, or gives special meaning to certain numbers, colors, or words (e.g., red is a bad color because once had a bad thought while wearing red shirt) |
1 |
| — Sexual Obsessions —
Forbidden or upsetting sexual thoughts, images, or impulses (e.g., unwanted images of violent sexual behaviour toward others, or unwanted sexual urges toward family members or friends) |
1 |
| Obsessions about sexual orientation (e.g., that he or she may be gay or may become gay when there is no basis for these thoughts) | 1 |
| Other sexual obsessions (Describe) | |
| — Miscellaneous Compulsions —
Fear of doing something embarrassing (e.g., appearing foolish, burping, having “bathroom accident”) |
1 |
| The need to know or remember things (e.g., insignificant things like license plate numbers, bumper stickers, T-shirt slogans) | 1 |
| Fear of saying certain things (e.g., because of superstitious fears, fear of saying “thirteen”) | 1 |
| Fear of not saying the right thing (e.g., fear of having said something wrong or not using “perfect” word) | 1 |
| Intrusive (nonviolent) images (e.g., random, unwanted images that come into his or her mind) | 1 |
| Intrusive sounds, words, music, or numbers (e.g., hearing words, songs, or music in his or her mind that can’t stop; bothered by low sounds like clock ticking or people talking) | 1 |
| Current | |
| Uncomfortable sense of incompleteness or emptiness unless things done “just right” | 1 |
| Other obsessions (Describe) | |