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Staff Initials__________
COMBINE
Brief Symptom Inventory (BSI ver. A)
Center
Participant #
Participant Initials
Week
Sequence
0 1
Date
/
mo.
Staff ID
/
da.
yr.
Instructions: Below is a list of problems that people sometimes have. Please read each one carefully. Then
circle the number that best describes how much that problem has distressed or bothered you during the past 7
days including today. The numbers refer to the following descriptive phrases:
0=Not at all
2=Moderately
3=Quite a bit
4=Extremely
2) . Faintness or dizziness.............................................................................................. 0
14) Feeling lonely even when you are with people ........................................................ 0
BSI_1 (10/10/00)
Page 1 of 3
Center
Participant #
Participant Initials
Week
Sequence
0 1
Date
/
mo.
0=Not at all
Staff ID
/
da.
yr.
2=Moderately
3=Quite a bit
4=Extremely
24) Feeling that you are watched or talked about by others ...........................................0
31) Having to avoid certain things, places, or activities because they frighten you..........0
34) The idea that you should be punished for your sins..................................................0
BSI_1 (10/10/00)
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Center
Participant #
Participant Initials
Week
Sequence
0 1
Date
/
mo.
0=Not at all
Staff ID
/
da.
yr.
2=Moderately
3=Quite a bit
4=Extremely
48) Others not giving you proper credit for your achievements..................................... 0
51) Feeling that people will take advantage of you if you let them ................................ 0
BSI_1 (10/10/00)
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