| Patient: | Clifford Aguilar | MHScales.com |
| Reported to: | Dr. Rachael Cummings | Code: 78-SAMPLE |
| Completed: | Apr 20, 2024 15:26 | Summary |
| Test | Result | Range | Subscales | Interpretation |
|---|---|---|---|---|
| PHQ-9 depression | 15 | [0-27] | Self-harm: 2 [0-3] Difficulty: 1 [0-3] | Moderately severe |
| ASRS-v1.1 ADHD | 38 | [0-72] | Part A: 4 (+) [0-6] Part B: 5 [0-12] Inattentive: 16 [0-36] Hyperactive: 19 [0-36] | Usual cutoff for ADHD screening is ≥ 4 items in Part A. |
| WSAS disability | 13 | [0-40] | ||
| PCL-5 trauma | 44 | [0-80] | B: Intrusion: 4 (+) [0-5, ≥1] C: Avoidance: 2 (+) [0-2, ≥1] D: Cognitions/Mood: 5 (+) [0-7, ≥2] E: Arousal/Reactivity: 3 (+) [0-6, ≥2] | Usual cutoff for PTSD screening is ~31-33, or '+' for all of criteria B-E, signifying sufficient responses of 'Moderately' or above. |
| DES-II dissociation | 12.5% | [%] | Amnesia: 15% Absorption: 10.9% Depersonalization / Derealization: 11.4% |
phq9;0;0133111321
asrs;0;123432120123144230
wsas;0;-23422
pcl5;0;23133433033320130331
des;0;0012300220221140052200041001
| Patient: | Clifford Aguilar | MHScales.com |
| Reported to: | Dr. Rachael Cummings | Code: 78-SAMPLE |
| Completed: | Apr 20, 2024 15:26 | Scale 1 of 5 |
| Not at all | Several days | More than half of days | Nearly every day | |
|---|---|---|---|---|
| 1. Little interest or pleasure in doing things. | X | |||
| 2. Feeling down, depressed, or hopeless. | X | |||
| 3. Trouble falling/staying asleep, sleeping too much. | X | |||
| 4. Feeling tired or having little energy. | X | |||
| 5. Poor appetite or overeating. | X | |||
| 6. Feeling bad about yourself, or that you are a failure, or have let yourself or your family down. | X | |||
| 7. Trouble concentrating on things, such as reading the newspaper or watching TV. | X | |||
| 8. Moving or speaking so slowly that other people could have noticed. Or the opposite; being so fidgety or restless that you have been moving around more than usual. | X | |||
| 9. Thoughts that you would be better off dead or of hurting yourself in some way. | X |
If you checked off any problems in the 9 questions above, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
| [ ] Not difficult at all | [ X ] Somewhat difficult | [ ] Very difficult | [ ] Extremely difficult |
| Score: | 15 | [0-27] |
Interpretation: Moderately severe
| Patient: | Clifford Aguilar | MHScales.com |
| Reported to: | Dr. Rachael Cummings | Code: 78-SAMPLE |
| Completed: | Apr 20, 2024 15:26 | Scale 2 of 5 |
| Never | Rarely | Sometimes | Often | Very Often | |
|---|---|---|---|---|---|
| 1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done? | X | ||||
| 2. How often do you have difficulty getting things in order when you have to do a task that requires organization? | X | ||||
| 3. How often do you have problems remembering appointments or obligations? | X | ||||
| 4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started? | X | ||||
| 5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time? | X | ||||
| 6. How often do you feel overly active and compelled to do things, like you were driven by a motor? | X | ||||
| 7. How often do you make careless mistakes when you have to work on a boring or difficult project? | X | ||||
| 8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work? | X | ||||
| 9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly? | X | ||||
| 10. How often do you misplace or have difficulty finding things at home or at work? | X | ||||
| 11. How often are you distracted by activity or noise around you? | X | ||||
| 12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated? | X | ||||
| 13. How often do you feel restless or fidgety? | X | ||||
| 14. How often do you have difficulty unwinding and relaxing when you have time to yourself? | X | ||||
| 15. How often do you find yourself talking too much when you are in social situations? | X | ||||
| 16. When in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves? | X | ||||
| 17. How often do you have difficulty waiting your turn in situations when turn taking is required? | X | ||||
| 18. How often do you interrupt others when they are busy? | X |
| Score: | 38 | [0-72] |
| Part A: | 4 (+) | [0-6] |
| Part B: | 5 | [0-12] |
| Inattentive: | 16 | [0-36] |
| Hyperactive: | 19 | [0-36] |
Interpretation: Usual cutoff for ADHD screening is ≥ 4 items in Part A.
| Patient: | Clifford Aguilar | MHScales.com |
| Reported to: | Dr. Rachael Cummings | Code: 78-SAMPLE |
| Completed: | Apr 20, 2024 15:26 | Scale 3 of 5 |
1. Because of my problem, my ability to work is impaired (including paid work, unpaid volunteer work or training).
| 0 not at all |
1 |
X2 slightly |
3 |
4 definitely |
5 |
6 markedly |
7 |
8 very severely |
2. Because of my problem, my home management is impaired (e.g., cleaning, tidying, shopping, cooking, looking after home or children, paying bills).
| 0 not at all |
1 |
2 slightly |
X3 |
4 definitely |
5 |
6 markedly |
7 |
8 very severely |
3. Because of my problem, my social leisure activities are impaired (done with other people, e.g. parties, bars, clubs, outings, visits, dating, home entertaining).
| 0 not at all |
1 |
2 slightly |
3 |
X4 definitely |
5 |
6 markedly |
7 |
8 very severely |
4. Because of my problem, my private leisure activities are impaired (done alone, e.g. reading, gardening, collecting, sewing, walking alone).
| 0 not at all |
1 |
X2 slightly |
3 |
4 definitely |
5 |
6 markedly |
7 |
8 very severely |
5. Because of my problem, my ability to form and maintain close relationships with others, including those I live with, is impaired.
| 0 not at all |
1 |
X2 slightly |
3 |
4 definitely |
5 |
6 markedly |
7 |
8 very severely |
| Score: | 13 | [0-40] |
| Patient: | Clifford Aguilar | MHScales.com |
| Reported to: | Dr. Rachael Cummings | Code: 78-SAMPLE |
| Completed: | Apr 20, 2024 15:26 | Scale 4 of 5 |
| Not at all | A little bit | Moderately | Quite a bit | Extremely | |
|---|---|---|---|---|---|
| 1. Repeated, disturbing, and unwanted memories of the stressful experience? | X | ||||
| 2. Repeated, disturbing dreams of the stressful experience? | X | ||||
| 3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)? | X | ||||
| 4. Feeling very upset when something reminded you of the stressful experience? | X | ||||
| 5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)? | X | ||||
| 6. Avoiding memories, thoughts, or feelings related to the stressful experience? | X | ||||
| 7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)? | X | ||||
| 8. Trouble remembering important parts of the stressful experience? | X | ||||
| 9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)? | X | ||||
| 10. Blaming yourself or someone else for the stressful experience or what happened after it? | X | ||||
| 11. Having strong negative feelings such as fear, horror, anger, guilt, or shame? | X | ||||
| 12. Loss of interest in activities that you used to enjoy? | X | ||||
| 13. Feeling distant or cut off from other people? | X | ||||
| 14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)? | X | ||||
| 15. Irritable behavior, angry outbursts, or acting aggressively? | X | ||||
| 16. Taking too many risks or doing things that could cause you harm? | X | ||||
| 17. Being “superalert” or watchful or on guard? | X | ||||
| 18. Feeling jumpy or easily startled | X | ||||
| 19. Having difficulty concentrating? | X | ||||
| 20. Trouble falling or staying asleep? | X |
| Score: | 44 | [0-80] |
| B: Intrusion: | 4 (+) | [0-5, ≥1] |
| C: Avoidance: | 2 (+) | [0-2, ≥1] |
| D: Cognitions/Mood: | 5 (+) | [0-7, ≥2] |
| E: Arousal/Reactivity: | 3 (+) | [0-6, ≥2] |
Interpretation: Usual cutoff for PTSD screening is ~31-33, or '+' for all of criteria B-E, signifying sufficient responses of 'Moderately' or above.
| Patient: | Clifford Aguilar | MHScales.com |
| Reported to: | Dr. Rachael Cummings | Code: 78-SAMPLE |
| Completed: | Apr 20, 2024 15:26 | Scale 5 of 5 |
| 1. Some people have the experience of driving or riding in a car or bus or subway and suddenly realizing that they don’t remember what has happened during all or part of the trip. | X | – | – | – | – | – | – | – | – | – | – | 0% |
| 2. Some people find that sometimes they are listening to someone talk and they suddenly realize that they did not hear part or all of what was said. | X | – | – | – | – | – | – | – | – | – | – | 0% |
| 3. Some people have the experience of finding themselves in a place and have no idea how they got there. | – | X | – | – | – | – | – | – | – | – | – | 10% |
| 4. Some people have the experience of finding themselves dressed in clothes that they don’t remember putting on. | – | – | X | – | – | – | – | – | – | – | – | 20% |
| 5. Some people have the experience of finding new things among their belongings that they do not remember buying. | – | – | – | X | – | – | – | – | – | – | – | 30% |
| 6. Some people sometimes find that they are approached by people that they do not know, who call them by another name or insist that they have met them before. | X | – | – | – | – | – | – | – | – | – | – | 0% |
| 7. Some people sometimes have the experience of feeling as though they are standing next to themselves or watching themselves do something and they actually see themselves as if they were looking at another person. | X | – | – | – | – | – | – | – | – | – | – | 0% |
| 8. Some people are told that they sometimes do not recognize friends of family members. | – | – | X | – | – | – | – | – | – | – | – | 20% |
| 9. Some people find that they have no memory for some important events in their lives (for example, a wedding or graduation). | – | – | X | – | – | – | – | – | – | – | – | 20% |
| 10. Some people have the experience of being accused of lying when they do not think that they have lied. | X | – | – | – | – | – | – | – | – | – | – | 0% |
| 11. Some people have the experience of looking in a mirror and not recognizing themselves. | – | – | X | – | – | – | – | – | – | – | – | 20% |
| 12. Some people have the experience of feeling that other people, objects, and the world around them are not real. | – | – | X | – | – | – | – | – | – | – | – | 20% |
| 13. Some people have the experience of feeling that their body does not seem to belong to them. | – | X | – | – | – | – | – | – | – | – | – | 10% |
| 14. Some people have the experience of sometimes remembering a past event so vividly that they feel as if they were reliving that event. | – | X | – | – | – | – | – | – | – | – | – | 10% |
| 15. Some people have the experience of not being sure whether things that they remember happening really did happen or whether they just dreamed them | – | – | – | – | X | – | – | – | – | – | – | 40% |
| 16. Some people have the experience of being in a familiar place but finding it strange and unfamiliar. | X | – | – | – | – | – | – | – | – | – | – | 0% |
| 17. Some people find that when they are watching television or a movie they become so absorbed in the story that they are unaware of other events happening around them. | X | – | – | – | – | – | – | – | – | – | – | 0% |
| 18. Some people find that they become so involved in a fantasy or daydream that it feels as though it were really happening to them. | – | – | – | – | – | X | – | – | – | – | – | 50% |
| 19. Some people find that they sometimes are able to ignore pain. | – | – | X | – | – | – | – | – | – | – | – | 20% |
| 20. Some people find that they sometimes sit staring off into space, thinking of nothing, and are not aware of the passage of time. | – | – | X | – | – | – | – | – | – | – | – | 20% |
| 21. Some people sometimes find that when they are alone they talk out loud to themselves. | X | – | – | – | – | – | – | – | – | – | – | 0% |
| 22. Some people find that in one situation they may act so differently compared with another situation that they feel almost as if they were two different people. | X | – | – | – | – | – | – | – | – | – | – | 0% |
| 23. Some people sometimes find that in certain situations they are able to do things with amazing ease and spontaneity that would usually be difficult for them (for example, sports, work, social situations, etc.). | X | – | – | – | – | – | – | – | – | – | – | 0% |
| 24. Some people sometimes find that they cannot remember whether they have done something or have just thought about doing that thing (for example, not knowing whether they have just mailed a letter or have just thought about mailing it). | – | – | – | – | X | – | – | – | – | – | – | 40% |
| 25. Some people find evidence that they have done things that they do not remember doing. | – | X | – | – | – | – | – | – | – | – | – | 10% |
| 26. Some people sometimes find writings, drawings, or notes among their belongings that they must have done but cannot remember doing. | X | – | – | – | – | – | – | – | – | – | – | 0% |
| 27. Some people sometimes find that they hear voices inside their head that tell them to do things or comment on things that they are doing. | X | – | – | – | – | – | – | – | – | – | – | 0% |
| 28. Some people sometimes feel as if they are looking at the world through a fog, so that people and objects appear far away or unclear. | – | X | – | – | – | – | – | – | – | – | – | 10% |
| Score: | 12.5% | [%] |
| Amnesia: | 15% | |
| Absorption: | 10.9% | |
| Depersonalization / Derealization: | 11.4% |