Name: ________________________________________________Age: ______________________________

Gender: M ( ) F ( ) Marital status:______________ Nº clinic history:___________________

Instruction: ________________ Occupation: ________________ Place of birth: _______________

SELF REPORTED QUESTIONNAIRE (SRQ) YES NO

1 Do you often have headeaches?
2 Is your appetite poor?
3 Do you sleep badly?
4 Do your hands shake?
5 Are you easili frightened?
6 Do you feel nervous, tense or worried?
7 Is your digestion poor? Yes
8 Do you have trouble thinking clearly?
9 Do you feel unhappy?
10 Do you cry more than usual?
11 Do you find it difficult to enjoy your daily activities?
12 Do you find it difficult to make decisions?
13 Is your daily work suffering?
14 Are you unable to play a useful part in life?
15 Have you lost interest in things?
16 Do you feel that you are a worthless person?
17 Has the thought of ending your life been on your mind?
18 Do you feel tired all the time?
19 Do you have uncomfortable feelings in your stomach?
20 Are you easily tired?
21 Do you feel that someone is chasing you to cause you
harm?
22 Are you a person who possesses special powers?
23 Have you noticed interference or anything unusual in
your thinking?
24 Hears voices without knowing where they come from or
that other people can't hear?

Distrito 01D01 – SALUD • Av. Huayna Cápac 1-270 • Teléfono: 593 (7) 4109189 / 4109202 • Cuenca - Ecuador
www.salud.gob.ec
 25 Have you had seizures, seizures or falls on the ground
with arm and leg movements: with tongue bites or loss of
consciousness?
26 Have you ever thought your family friends, doctor that
you're drinking too much liquor?
27 Have you ever wanted to stop drinking but couldn't?
28 Have you ever had difficulties at work, studying because
of drinking, such as drinking at school, working and
missing them?
29 Have you been in a quarrel or have you been arrested
while drunk?
30 Did you ever think that you drank a lot?

CALIFICACION GENERAL DEL CUESTIONARIO DSE SINTOMAS SRQ

1 2 3 6 9 10 11 12 12 14 15 16 17 18 19
DEPRESSION
1 3 4 5 6 7 8 19 20
ANGUISH OR
ANXIETY
21 22 23 24
PSYCHOSIS
EPILEPSY 25

EPILEPSY 26 27 28 29 30

INTERPRETATION
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Distrito 01D01 – SALUD • Av. Huayna Cápac 1-270 • Teléfono: 593 (7) 4109189 / 4109202 • Cuenca - Ecuador
www.salud.gob.ec
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EXAMINADOR

Distrito 01D01 – SALUD • Av. Huayna Cápac 1-270 • Teléfono: 593 (7) 4109189 / 4109202 • Cuenca - Ecuador
www.salud.gob.ec