SAS-II Interview

SOCIAL ADJUSTMENT SCALE-II
Interview
Patient Name: Patient I.D. # _____________ Date: ________________
Rater Initial: _____________ Assessment:
GENERAL INSTRUCTIONS
TEXT IN UPPER CASE REPRESENTS INSTRUCTIONS TO THE INTERVIEWER.
TEXT IN BOTH UPPER AND LOWER CASE IS TO BE READ TO THE PATIENT.
PHRASES IN PARENTHESES SHOULD BE REPLACED BY TERM APPROPRIATE TO PERSON BEING

INTERVIEWED. FOR EXAMPLE--(date) "the first of the year"; (he) "your husband" "your cousin" "he".
ITALICIZED TEXT, Has anyone had to talk to you about your work? ARE PROBE QUESTIONS WHICH ONLY
NEED TO BE ASKED IF INSUFFICIENT INFORMATION IS PROVIDED BY THE LEAD QUESTIONS.
LEAD QUESTIONS MUST ALWAYS BE ASKED.
NON-SPECIFIC PROBES SUCH AS--Could you tell me more about that? Could you give me an
example/Anything else?--ARE ALWAYS IN ORDER.
IT IS ALSO ALWAYS PERMISSIBLE TO REPEAT WHAT THE PATIENT HAS SAID AS A QUESTION TO
ELICIT FURTHER INFORMATION.
OTHER THAN THESE NON-SPECIFIC PROBES, OTHER QUESTIONS SHOULD BE MINIMIZED.
DEFINED ANCHOR POINTS FOR EACH ITEM ARE SET OFF BETWEEN LINES AND NUMBERED. ONLY THE
NUMBERS ARE TO BE ENTERED ON THE RECORDING SHEET.
IF NECESSARY, PHRASES FROM CATEGORIES MAY BE READ TO PATIENT. ALWAYS READ AT LEAST
TWO CATEGORIES AND ALTERNATE ORDER, I.E, HIGHER OR LOWER FIRST.
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THE INTRODUCTION SERVES TO
1. ESTABLISH RAPPORT
2. DEFINE THE RATING PERIOD AS "THE PRIOR MONTH"
3. DEFINE ANCHORS FOR "THE MONTH" E.G. "SINCE CHRISTMAS", "SINCE (X) GOT OUT OF THE
HOSPITAL." (DO NOT USE DATA FROM WHEN PATIENT WAS IN HOSPITAL.)
We are interested in finding out how you have been doing in the last month, that would be from (date) to now. I'll be
asking you some questions about work family life and free time. I'll be reading some of the questions just to be sure I get
them right and making a note of your answers. Try to answer all the questions for the last month. If any question doesn't
make sense to you, let me know. Do you have any questions before we start?
I. INSTRUMENTAL ROLE DETERMINATION
THE FOLLOWING QUESTIONS ARE DESIGNED TO HELP DETERMINE THE APPROPRIATE ROLE
CLASSIFICATIONS FOR THE PATIENT. EVERYONE IS A WORKER.
SCHOOL STATUS
Are you still in school? (In a training program?) IF IN SCHOOL: Do you go to school full time or part time?
HOMEMAKING STATUS
Are you the homemaker in the household? Are you responsible for your own meals? Are you responsible for most of
the cleaning, shopping and cooking? Who cleans the bathroom?
WORK STATUS
Do you usually have a full or part time job? (Volunteer? Sheltered Workshop?) IF YES: What is your usual job? Have
you been working since (date)? What other kinds of work have you done? IF NO: When was the last time you worked
regularly (at all)? What kind of work was that? IF PART TIME: How many hours/week do you work? Why aren't you
working full time?
1. Role(s)
FOR THE PURPOSES OF THIS SCALE, IF A PERSON PERFORMS MULTIPLE ROLES, THEN QUESTIONS IN
ALL PERTINENT ROLE AREAS SHOULD BE ASKED (E.G., A WOMAN CAN BE BOTH A WORKER AND A
HOMEMAKER).
-- TO BE CLASSIFIED AS A "STUDENT" THE PATIENT MUST BE IN SCHOOL HALFTIME OR MORE.
-- TO BE CLASSIFIED AS A "HOMEMAKER" THE PATIENT MUST HAVE MAJOR RESPONSIBILITY FOR A
HOUSEHOLD OR MUST LIVE ALONE (NOTE THAT A MAN CAN BE CLASSIFIED AS A "HOMEMAKER.")
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NOTE: CLASSIFICATION DOES NOT REFLECT CURRENT PERFORMANCE. CLASSIFICATION AS
"STUDENT' OR “HOMEMAKER" DOES NOT NECESSARILY EXCLUDE CLASSIFICATION ALSO AS A
"WORKER."
WHICH INSTRUMENTAL ROLES) WILL BE EVALUATED?

(AT LEAST ONE MUST BE RECORDED)
1. Role(s) (ON RESPONSE SHEET, CIRCLE "YES" OR "NO" FOR EACH ROLE)
1 = Student
2 = Homemaker
3 = Worker
(IF "WORKER" QUESTIONS WILL BE ASKED, CONTINUE WITH SECTION II (WORKER). OTHERWISE SKIP
TO SECTION III (HOMEMAKER), P. 8)
II. WORKER
2. Working Status (RECORD ONLY ONE)

1 = Patients who are currently working competitive employment (paid—regular schedule—can be part-time).
2 = Patients who are currently working noncompetitively (volunteer, vocational training, sheltered workshop)
3 = Patients who are not currently working and have been unemployed for 2 years or less
4 = Patients who are not currently working and have been unemployed for more than 2 years
5 = None of the above (e.g., never held employment)
6 = Casual Labor (no set schedule, typically just a few hours a week—e.g. occasional lawn care, babysitting)
(IF WORKING STATUS IS 2, 3, 4, 5, or 6 SKIP TO ITEM 11, P. 6. OTHERWISE (IF WORKING STATUS IS 1
CONTINUE.)
3. Schedule Work
During the past month, how many hours a week were you scheduled to work?
3. Number of scheduled work hours per week

1 = 40 hours per week
2 = 30-39 hours per week
5 = Use for casual labor
6 = Less than 10 hours per week
8= Don't know
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4. Time Lost (Work)
Have you missed any time from work this last month? How many days was that?
Was that a vacation? Did you leave work early or go in late any days?
INCLUDE TIME LOST DUE TO: PHYSICAL ILLNESS, MENTAL ILLNESS, DAYS LAID OFF, DAYS
UNEMPLOYED DO NOT INCLUDE PAID VACATION UNLESS TAKEN BECAUSE OF ILLNESS.
4. Time Lost (Work)

1 = None or one scheduled day
2 = Up to 2 scheduled days
3 = 3 or 4 scheduled days
4 = 5 to 9 scheduled days
5 = 10 or more scheduled days
6 = Casual labor performed
8 = Don't know
5. Performance Adequacy (Work)
Have you been doing your job well during the last month? Have you had trouble keeping up with your work?
Has anyone had to speak to you about your work?
RATE DESCRIBED IMPAIRMENT, NOT PERSONAL FEELINGS. OTHERS WOULD BE LIKELY TO

NOTICE OR COMMENT
5. Performance Adequacy (Work)

1 = No impairment
2 = Adequate but some impairment
3 = Moderate impairment
4 = Marked impairment
5 = Extreme impairment
8 = Don't know
9 = Does not apply
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6. Feelings of Adequacy (Work)
Have you been doing your (work) as well as possible or do you feel you could do better? Have you felt that you might
have done a poor job at any time in the last month?
RATE PATIENT'S SUBJECTIVE FEELINGS ABOUT PERFORMANCE.
6. Feelings of Adequacy (Work)

1 = Almost always feels adequate or able to handle things
2 = Usually or often feels adequate or able to handle things
3 = Sometimes feels adequate or able to handle things.
4 = Rarely feels adequate or able to handle things
5 = Almost never feels adequate or able to handle things
8 = Don't know
9 = Does not apply
7. Friction (Work)
How have you and (people at work) been getting along in the last month? Are there things they did which annoyed you or
made you angry?
IF YES: Did you hold your feelings in? Did the other person know you were upset? Are there things you did which
annoyed them or made them angry? Did you argue much? Have there been any open disagreements? How Often? How
serious have those arguments been?
Is there anyone you avoid because you knew you'd get into an argument?
RATE OVERT BEHAVIOR INCLUDING EXPRESSED FEELINGS OF ANGER, ARGUMENTS, OVERT

ANNOYANCE, WITHDRAWAL CONSIDER: SUPERVISOR, CO-WORKERS, CUSTOMERS.
7. Friction (Work)
1 = No friction and/or avoidance
2 = Minimal friction and/or avoidance
3 = Some friction and/or avoidance
4 = Moderate friction and/or avoidance
S = Extreme friction and/or avoidance
8 = Don't know
9 = Does not apply
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8. Distress (Work)
ASK ONLY IF NEEDED TO RATE
Have you felt upset or worried for any reason while doing your work this last month?
Did you ever have to stop doing your work because you were too upset to continue?
RATE PATIENTS FEELINGS.
BASE RATINGS ON BOTH FREQUENCY AND INTENSITY, DISTRESS INCLUDES BEING BLUE OR CRYING,
BEING TENSE OR JITTERY, HEART POUNDING, BUTTERFLIES INSIDE, TIREDNESS, ETC.
8. Distress (Work)
1 = Not at all distressed
2 = A little distressed
3 = Moderately distressed
4 = Very distressed
5 = Extremely distressed
8 = Don't know
9 = Does not apply
9. & 10. Affect (Work)
What did you like about your (work)?

Anything you disliked?
What did you like most ...least?
Have you found your (work) interesting this last month?
Have you been satisfied when your (work) is done?
9. Likes (Work)
1 = Likes many aspects of the work
2 = Likes some aspects of work with some minor dislikes
3 = Likes some, dislikes others equally
4 = Dislikes some but not entirely
5 = Dislikes many aspects of work
8 = Don't know
9 = Does not apply
10. Interest (Work)

1 = Very interested
2 = Somewhat interested
3 = Neutral
4 = Somewhat uninterested
5 = Very uninterested
8 = Don't know
9 = Does not apply
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11. Desire for Work
(ASK FOR ALL PATIENTS CLASSIFIED AS WORKERS WHO ARE NOT CURRENTLY WORKING
COMPETITIVELY (WORKING STATUS 2, 3, 4, 5, or 6). OTHERWISE (WORKING STATUS 1) SKIP TO
SECTION III (HOMEMAKER), P. 8-10.
Have you been interested in looking for work? Have you looked for work in the last month? How many times would you
say you've gone out and looked for work? Have you gone to an agency or consulted someone else (e.g., case
worker/counselor, friend/acquaintance) about available jobs?
11. Desire for Work

1 = Makes frequent efforts to seek work
2 = Makes moderate efforts to seek work
3 = Makes occasional or rare efforts to seek work
4 = Wants work but has not sought work
5 = Does not want work and has not sought work
8 = Don't know
9= NA
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III. HOMEMAKER
ASK FOR ALL PATIENTS WHO HAVE PRIMARY RESPONSIBILITY FOR HOUSEHOLD
OR WHO LIVE ALONE.
a. WILL HOMEMAKER ITEMS BE ASKED?
1=YES 2=NO
(IF NO, SKIP TO SECTION IV (STUDENT), P. 11.)
12. Homemaker Status (RECORD ONLY ONE)

1 = Patients who live with others in a household
2= Patients who live alone or share accommodations but have primary responsibility for their own
maintenance—laundry, cleaning, meals (e.g., Roommate, Boarder)
13. Time Lost (Homemaker) and
14. Performance Adequacy (Homemaker)
How have you been doing your work at home? Were there days in the last month when you had serious trouble doing the
housework? Could you tell me what those days were like? How many days in the last month did you feel that way?
RATE EACH AREA AND AVERAGE:
MEALS: Have you been making most of the meals in the last month? Is that different from the usual? Have you had
problems getting meals? What do you cook on an average day? Have you been taking short cuts (more carry-outs or
frozen dinners) than usual? Have you/the family had to eat out because you could not get dinner together? About
how often ?
CLEANING: Have you been keeping up with the house cleaning in the last month? Is that different from usual? Have
you had to let things slide? How often do you clean the bathroom? Mop the kitchen floor?
LAUNDRY: Have you been keeping up with the laundry in the last month? Has anyone run out of clean clothes?
GROCERIES: About how often have you been grocery shopping in the last month? Is that more or less--different from
usual? Do you have to make extra trips?
ERRANDS: Have you had problems keeping up with other shopping, errands and the things you have to do to run the
house like buying clothes, going to the drugstore, paying bills? Has anyone complained about you not doing household
tasks well?
13. Time Lost (Homemaker)

1 = Carries out all household tasks most of the time
2 = Usually carries out most tasks
3 = Carries out some but not others
4 = Usually does not carry out most tasks
5 = Almost always fails to carry out any task
8 = Don't know
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14. Performance Adequacy (Homemaker)
NOTICE OR COMMENT
1 = No impairment
3 = Moderate impairment (needed or received help)
4 = Marked impairment (needed or received substantial help)
5 = Extreme impairment or not functioning at all
8 = Don't know
Have you been doing your work around the house as well as possible or do you feel that you could do better?
Have you felt that you might have done a poor job at any time in the last month?
RATE PATIENT'S SUBJECTIVE FEELINGS ABOUT PERFORMANCE
15. Feelings of Adequacy (Homemaker)

3 = Sometimes feels adequate or able to handle things
8 = Don't know
16. Friction (Homemaker)
How have you been getting along with the people you have to deal with in carrying out homemaking tasks (jobs) in the
last month? I mean like shopkeepers, sales people, repairmen, supermarket checkout people and neighbors (EXCLUDE
CLOSE FRIENDS, FAMILY).
Are there things they did which annoyed you or made you angry? IF YES: Did you hold your feelings in? Did the other
person know you were upset?
Are there things you did which annoyed them or made them angry? Did you argue much? Have there been any open
disagreements? How often? How serious have those arguments been? Is there anyone you avoided because you knew
you'd get into an argument?

ANNOYANCE, WITHDRAWAL.
16. Friction (Homemaker)

5 = Extreme friction and/or avoidance
8 = Don't know
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17. Distress (Homemaker)
Have you felt upset of worried for any reason while doing your work around the house this last month? Did you
ever have to stop doing your work because you were too upset to continue?
RATE PATIENTS FEELINGS.
BASE RATINGS ON BOTH FREQUENCY AND INTENSITY. DISTRESS INCLUDES BEING BLUE OR CRYING,
BEING TENSE OR JITTERY, HEART POUNDING, BUTTERFLIES INSIDE, TIREDNESS, ETC.
17. Distress (Homemaker)

4 = Very distressed
8 = Don't know
18. & 19. Affect (Homemaker)
What did you like about your housework? Anything you disliked? What did you like most; ... least? Have you found the
work interesting this last month? Have you been satisfied when your work is done?
18. Likes (Homemaker)

2= Likes some aspects of work with some minor dislikes
8 = Don't know
19. Interest (Homemaker)

1 = Very interested
3 = Neutral
8 = Don't know
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IV. STUDENT
COMPLETE THE ITEMS IN THIS SECTION ONLY IF PATIENT IS DEFINED AS A STUDENT.
b. WILL STUDENT ITEMS BE ASKED?
1 = YES 2 = NO
(IF NO, SKIP TO SECTION V (CHORES), P. 14.)
20. Student Status

1 = PATIENTS WHO GO TO SCHOOL HALF-TIME OR MORE
21. Time Lost (Student)
Have you had to miss any days of school during the last month? How many times?
Why was that?
21. Time Lost (Student)

1 = None or one scheduled day
2 = Up to 2 scheduled days
3 = 3 or 3 scheduled days
4 = 5 to 9 scheduled days
5 = 10 or more scheduled days
8 = Don't know
22. Performance Adequacy (Student)
How have you been doing in your schoolwork?

Have you been able to keep up with assignments during the last month?
What about tests, have you had any tests? How did you do?
NOTICE OR COMMENT
22. Performance Adequacy (Student)

1 = No impairment
3 = Moderate impairment
4 = Marked impairment
5 = Extreme impairment or not functioning at all
8 = Don't know
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23. Feelings of Adequacy (Student)
Have you been doing your schoolwork as well as possible or do you feel you could do better? Have you felt that you
might have done a poor job at any time in the last month?
23. Feelings of Adequacy (Student)

8 = Don't know
24. Friction (Student)
How have you and the people at school (teachers and other students) been getting along in the last month? Are there
things they did which annoyed you or made you angry?
IF YES: Did you hold your feelings in? Did the other person know you were upset? Are there things you did which
annoyed them or made them angry? Did you argue much? Have there been any open disagreements? How often? How
serious have those arguments been? Is there anyone you avoided because you knew you'd get into an argument?

24. Friction (Student)

8 = Don't know
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25. Distress (Student)
Have you felt upset or worried for any reason while doing your schoolwork this last month?
Did you ever have to stop doing your school work because you were too upset to continue?
RATE PATIENT'S FEELINGS. BASE RATINGS ON BOTH FREQUENCY AND INTENSITY. DISTRESS
INCLUDES BEING BLUE OR CRYING, BEING TENSE OR JITTERY, HEART POUNDING, BUTTERFLIES
INSIDE, TIREDNESS, ETC.
25. Distress (Student)

4 = Very distressed
8 = Don't know
26. & 27. Affect (Student)
What did you like about your schoolwork? Anything you disliked? What did you like most;... least? Have you found
your schoolwork interesting this last month?
26. Likes (Student)

8 = Don't know
27. Interest (Student)

1 = Very interested
3 = Neutral
8 = Don't know
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V. CHORES
COMPLETE THIS SECTION FOR PATIENTS NOT CLASSIFIED AS HOMEMAKERS.
c. WILL CHORE ITEMS BE ASKED?
1=YES 2=NO
(IF NO, SKIP TO SECTION VI (PATIENT'S FINANCES), P. 16)
28. Performance Adequacy (Chores)
Do you have any jobs or chores around the house that you are responsible for like taking out the trash, making the bed,
doing some shopping, going to the cleaners, setting the table? What kinds of things are you expected to do around the
house? Did it bother you to have to do them? Have you had any trouble keeping up with these chores in the last month?
Have you been letting things slide during the last month? Does anyone complain about you not doing your chores
well?
NOTICE OR COMMENT
28. Performance Adequacy (Chores)

1 = Has chores to do around the house and has no difficulty doing them
2 = Usually carries out most chores with little difficulty
3 = Carries out some chores but not others or expresses some difficulty in executing them
4 = Usually does not carry out most chores
5 = Does not carry out any chores around the house or is not assigned any
8 = Don't know
29. Feelings of Adequacy (Chores)
Have you been doing your chores as well as possible or do you feel you could do better?
Have you felt that you might have done a poor job at any time in the last month?
29. Feelings of Adequacy (Chores)

4 = Rarely feels adequate or able to
8 = Don't know
9 = Does not apply (no chores assigned)
30. Friction (Chores)

Has anyone had to remind you about your chores?
IF YES: Have there been any arguments about this?
Is there anyone you avoided because you knew you'd get into an argument about chores?
30. Friction (Chores)

4= Moderate friction and/or avoidance
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8 = Don't know
31. Distress (Chores)
Have you felt upset or worried for any reason while doing your chores this last month? Did you ever have to
stop doing your chores because you were too upset to continue?
RATE PATIENT'S FEELINGS. BASE RATINGS ON BOTH FREQUENCY AND INTENSITY. DISTRESS
INCLUDES BEING BLUE OR CRYING, BEING TENSE OR JITTERY, HEART POUNDING, BUTTERFLIES
INSIDE, TIREDNESS, ETC.
31. Distress (Chores)

4 = Very distressed
8 = Don't know
32.& 33. Affect (Chores)
What did you like about your chores?

Anything you disliked?
What did you like most;... least?
Have you found them at all interesting this last month?
Have you been satisfied when your work is done?
32. Likes (Chores)

8 = Don't know
33. Interest (Chores)

1 = Very interested
3 = Neutral
8 = Don't know
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VI. PATIENT'S FINANCES
ASK FOR EVERYONE.
34. Income Source
What was your main source of support the last month? Are you receiving any assistance, like welfare?
34. Income Source

1 = Patient's earnings/sick leave
2 = Other household member's income
3 = SSDI, VA-SC
4 = Earnings of others outside household or loans from family
5 = Public assistance, welfare, SSI, VA-NSC
35. Economic Adequacy
In the last month, have you had enough money for basic expenses: Paying the rent,
food, and paying your bills? Is there money left over for other things?
IF NO, can you borrow or do you get money some other way?
Have you had to use savings?
Have you had to put off important things, such as doctor visits?
Have you had trouble with bill collectors? (rate a 4 or 5 if yes)
Note: If patient is not paying full living expenses (e.g. being supported by family or in subsided housing), rate higher.
35. Economic Adequacy

1 = Available funds and reserves adequate for incurred obligations and some money for
purchasing power remains
2 = Available funds and reserves adequate for incurred obligations but only restricted
purchasing power remains
3 = Available funds and reserves adequate only for incurred obligations
4 = Available funds and reserves somewhat inadequate for incurred obligations--
5 = Available funds and reserves very inadequate for incurred obligations
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VII. PRINCIPAL FAMILY MEMBER
ASK FOR EVERYONE.
36. Identification of Principal Family Member (PFM)
IN THIS SECTION, ASK QUESTIONS ABOUT THE FAMILY MEMBER/PARTNER TO WHOM CLIENT SAYS
HE/SHE IS CLOSEST. IN THE FOLLOWING ITEMS, CONTACT CAN BE IN PERSON, OR PHONE, E-MAIL, OR
REGULAR MAIL.
36. Principal Family Member (PFM)

1= Mother
2 = Father
3 = Sibling
4 = Spouse/Conjugal like Partner
5 = Other
8 = NA/no family—go to page 19 VIII
9 = No family contact in past month, but has PHM
Who are your closest relatives? To whom are you closest? (IF THE PARTICIPANT HAS A STEADY
GIRLFRIEND/BOYFRIEND WITH WHOM LONG-TERM CONTACT IS POSSIBLE, CONSIDER RATING HERE)
Now I'd like to talk to you about your family. Let's start with your (PFM).
37. Communication (PFM)
How have you been getting along with your (PFM) during the last month? Have you been able to talk easily with
(him/her)? What types of things did you talk about? Did you talk to (him/her) when you were upset or were having
problems? Did you talk to (him/her) when some things important happened? Did you talk about your feelings? Can
you give me an example? Have there been some things you've found it hard to talk about? Is this different than
usual? Are there things you feel you should've talked about but didn't?
37. Communication (PFM)

1 = Almost always talks easily to (PFM)
2 = Usually talks easily to (PFM)
3 = Sometimes does and sometimes doesn't talk easily to (PFM)
4 = Usually can't talk easily to (PFM)
5 = Never talks easily to (PFM)
9 = No contact in past month
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38. Friction (PFM)
Are there things (PFM) did which annoyed you or made you angry?
IF YES: Did you hold your feelings in? Did (he/she) know you were upset? Are there things you did which annoyed
(him/her) or made (him/her) angry? Did you argue much? Have there been any disagreements in the last month? How
many? How serious have those arguments been? Did you ever avoid (him/her) because you knew you'd get into an
argument?

38. Friction (PFM)

9 = No contact in past month, but no apparent avoidance
39. Adaptability
During the past month, if you and (PFM) didn't agree about something, what generally happened? Could you give me an
example? Even when you disagreed, did you see (PFM's) side of things? By the way, do you know what kind of things
make (PFM) happy or give (him/her) enjoyment? Do you know what makes (him/her) unhappy? Are there things you
have done to help the two of you get along? Could you give me an example?
39. Adaptability
1 =Patient is aware of and is able to adapt appropriately to PFM's needs or desires
2 =Patient is aware of PFM's needs or desires but has limited adaptability to them
3 =Patient has limited awareness of PFM's needs or desires and limited ability to adapt appropriately
4 =Patient has limited awareness of PFM's needs or desires and no ability to adapt appropriately
5 =Patient has no awareness of PFM's needs or desires and no ability to adapt appropriately
9 = No contact in past month
40. Independence (PFM)
TO RATE THIS ITEM, FIRST DETERMINE WHETHER CLIENT IS FUNCTIONING INDEPENDENTLY, THEN
ASSESS LEVEL OF HELP.
During the past month, have you turned to (PFM) for help of advice?
IF YES: What kinds of things have you needed help with? How about things like driving, shopping, getting a job, work
around the house, babysitting? Could you get along without this help? How much have you leaned on (him/her) when
things went wrong or you were upset this past month?
40. Independence (PFM)

1 = Independent--receives no help
2 = Independent and receives help
3 = Dependent and receives a lot of help
4 = Dependent and receives some help
5 = Dependent but receives no help (needs help but does not get it)
9 = Not Ratable
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41. Expressed Feelings-Affection
What have your feelings been toward (PFM) during the last month? Did you feel friendly? Did you dislike (him/her)?
Did you care for (him/her) even if you weren't getting along?
DO NOT RATE FRICTION. RATE PATIENT'S FEELINGS.
41. Expressed Feelings--Affection

1 = Likes most of the time
2 = Likes and dislikes about equally
3 = Indifferent
4 = Dislikes more of the time
5 = Dislikes most of the time
VIII. PATIENT'S EXTENDED FAMILY

(i.e., Rest of Patient’s family—both co-residents and extended family—but not PFM)
ASK FOR EVERYONE.
We've talked about your (PFM). Do you have other relatives with whom you are in contact? Anyone else in the house?
Anybody outside the area with whom you're in touch? Who is that?
ASK ABOUT BROTHERS AND SISTERS, IN-LAWS, OTHER RELATIVES?
ASK ITEMS 42-44 ABOUT THIS RELATIVE, IF MORE THAN ONE RELATIVE IDENTIFIED: To whom do you
feel closest?
42. Contact (Extended Family)

(TAKE AN AVERAGE, OVER REPORTED CONTACTS)
Have you seen or heard from (relative) in the last month? Have you made an effort to keep in touch with (relative) or do
you wait for (him/her) to contact you? Did you call (relative)? Did (relative) call you? Who usually arranged getting
together?
42. Contact (Extended Family)

1 = Initiates contact regularly
2 = Initiates some contact (50/50)
3 = Relies on relative to initiate most contacts
4 = Relies on relative to initiate all contacts
5 = No contact with relative at all
8 = Don't know
9 = Does not apply (No ratable extended family) SKIP TO SECTION IX P. 21.
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43. Independence(Extended Family)
During the past month, have you turned to (relative) for help or advice?
IF YES: What kings of things have you needed help with? How about things like driving, shopping, getting a job, work
around the house, babysitting? Emotional support? How often has this happened? Do you think you could have gotten
along without this help?
43. Independence (Extended Family)

1 = Independent-- receives no help
2 = Independent and receives help
3 = Dependent and receives a lot of help
4 = Dependent and receives some help
5 = Dependent but receives no help
8 = Don't know
9 = Does not apply (no family)
44. Friction (Extended Family)
How have you been getting along with (relative) in the last month? Are there things (relative) did which annoyed you or
made you angry? Are there things you did which annoyed (him/her) or made (him/her) angry? Did you argue much with
(relative)? Have there been any disagreements in the last month? How many? How serious have those arguments
been? Did you ever avoid one another because you think you'd get into an argument? -

44. Friction (Extended Family)

8 = Don't know
9 = No family or contact in past month, but no apparent avoidance
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IX. CONCERN FOR FAMILY MEMBERS
INCLUDE PATIENT'S HOUSEHOLD, PFM HOUSEHOLD (IF DIFFERENT) AND EXTENDED FAMILY.
RATING ANCHOR POINTS FOR ITEMS IN THIS SECTION INCLUDE BOTH INTENSITY AND FREQUENCY.
RATE ON THE BASIS OF THE GREATEST DISABILITY, E.G., MILD WORRY ALL THE TIME OR SEVERE
WORRY SOME OF THE TIME ARE BOTH RATED "5".
45. Worry
Have you worried about things happening to your family (specify) during the last month? Has anyone caused you to
worry much? What kinds of things have you been worried about?
RATE PATIENT'S FEELINGS.
45. Worry
1 = Almost never feels worried
2 = Sometimes (mildly) feels worried
3 = Often (moderately) feels worried
4 = Usually (markedly) feels worried
5 = Almost always (severely) feels worried
9= Does not apply; no apparent living family
46. Guilt
In the last month, have you had the feeling that you let your family down? How did you let them down? Have you felt
badly about it? This could include relatives who have passed ….
46. Guilt
1 = Almost never feels guilty
2 = Sometimes (mildly) feels guilty
3 = Often (moderately) feels guilty
4 = Usually (markedly) feels guilty
5 = Almost always (severely) feels guilty
47. Wronged
In the last month, have you had the feeling that your family has let you down? Have they treated you unfairly or
unjustly? How did they let you down? Have you felt bitter?
47. Wronged
1 = Almost never feels let down or treated unfairly
2 = Sometimes (mildly) feels let down or treated unfairly
3 = Often (moderately) feels let down or treated unfairly
4 = Usually (markedly) feels let down or treated unfairly
5 = Almost always (severely) feels down or treated unfairly
21 of 30
X. SOCIAL LEISURE
ASK FOR EVERYONE.
48. Leisure Activities
What kinds of things did you do in your free time? (SKILLFUL ACTIVITIES AND SCHEDULED GROUP
ACTIVITIES DENOTE BETTER SCORES)
Do you have any hobbies or things you specially enjoy like sports, political activities, gardening, special
cooking, favorite TV programs, magazine column? Could you. tell me about these. (get specifics)
48. Leisure Activities

1 = Well developed, specific interests or activities--participates more than once a week—must require skill or
training
2 = Definite interests or activities--devotes regular but less frequent time—at least weekly activity
(more than just passive television watching)
3 = Some specific interest, but activity is irregular
4 = Some superficial interests, favorite TV program or magazine, follows a team, or comic, etc.
5 = Absence of any specific interests or activities, e.g., non-discriminating TV viewing
49.& 50. Social Contacts
Have you had a chance to do anything socially with your friends or family in the last month? Like going to a movie or
going out to eat or someplace you saw people you knew--like at church or a club meeting? Have you had people over
to the house? Have you spent time with them when they came over? How many times in the last month have you
(activities mentioned)? With whom have you been doing these things? Did you generally make the plans or did
someone usually ask you to come along? Did you tend to join in conversation or tend to be quiet?
INCLUDE ENTERTAINING OR VISITING RELATIVES OR GOING OUT IN COMPANY OF OTHERS
INCLUDING MOVIES, SPORTS EVENTS, RESTAURANTS, BARS SHOPPING WITH RELATIVES, PLAYING
CARDS, PARTIES, CLUB MEETINGS. INCLUDE CHURCH ATTENDANCE ONLY IF PATIENT SOCIALIZES.
INCLUDE 12 STEP GROUPS IF INCLUDES SOCIALIZING BUT NOT THERAPY GROUPS. INCLUDE PATIENT
CONTACTS OUTSIDE OF GROUPS, ATTENDANCE AT CLINIC SOCIAL FUNCTIONS, AND EFFORTFUL
ACTIVITY WITH OTHER CLINIC MEMBERS OUTSIDE OF THERAPY GROUPS. DO NOT INCLUDE SOLE
ACTIVITY WITH STAFF.
49. Frequency of Social Contacts

1 = 2 or more time a week
2 = About once a week
3 = 2 or 3 times during past month
4 = Only one activity reported during month
5 = Not at all during last month
50. Degree of Activity (Social Contacts)

1 = Actively participates with others and/or initiates contacts
2 = Sometimes participates with others and/or initiates contacts (50/50)
3 = Responds to contacts initiated by others
4 = Sometimes responds to contacts initiated by others
5 = Completely passive-does not interact with others even if in a group situation
9 = Does not apply (completely inactive)
22 of 30
51. Obstacles
Considering what you've been telling me about what you've been (doing/not doing), have there been any problems in
your getting out and meeting people in the last month? Would you have gotten out and done more if you had a ride, if
money
wasn't a problem, if you had someone to go with, if you weren't working so hard? What are the
obstacles/impediments to you getting out and meeting people?
INCLUDE ECONOMIC, ENVIRONMENTAL AND SOCIAL FACTORS, E.G., NO MONEY NO
TRANSPORTATION, NO FRIENDS OR FAMILY, WORK RELATED REASONS.
ASK EVEN IF SOCIAL CONTACTS RATED 1 OR 2. RATE OBSTACLES EVEN IF NOT APPARENT TO
PATIENT
51. Obstacles
1 = Numerous (4) realistic external obstacles to social contact
2 = Quite a few (3) realistic external obstacles to social contact
3 = Some (2) realistic external obstacles to social contact
4 = Very few (1) realistic external obstacles to social contact
5 = No (0) realistic external obstacles to social contact
52. Social Comfort
During the last month, did you enjoy being with people?
IF NO CONTACT, ASK: If you had to be with people, did you enjoy it? Did you sometimes feel ill at ease or
uncomfortable? What did you like most about being with people? What did you like least? Did you feel anxious to get
away or to be alone when with people?
RATE FOR ALL PATIENTS WHETHER OR NOT THERE ARE CONTACTS.
52. Social Comfort

1 = Had contacts and was rarely ill at ease
2 = Had contacts and was sometimes ill at ease
3 = Had contacts and was often ill at ease or had no contacts but doesn't anticipate discomfort
4 = Had no contacts and anticipates some discomfort
5 = Had no contacts and anticipates severe discomfort
23 of 30
XI. INTERPERSONAL CONTACTS (FRIENDS)
ASK FOR EVERYONE.
We've talked about your family and what you do in your spare time. Now could you tell me about your friends? Not your
family (or your romantic interests, like a boy friend or girl friend) but any friends whom you're interested in or care
about.
IF PATIENT ASKS FOR DEFINITION OF "FRIEND": Someone who you consider a friend.
EXCLUDE: SIBLINGS, PARENTS, CHILDREN, CLOSE AUNTS AND UNCLES, SPOUSE'S SIBLINGS AND
PARENTS, CO-WORKERS UNLESS THERE IS CONTACT OUTSIDE OF WORK, OLD FRIENDS WITH NO
RECENT CONTACT, OTHER PATIENTS UNLESS THERE IS CONTACT OUTSIDE OF CLINICAL SETTINGS.
53. Frequency of Contact (Friends)
Have you seen any of your friends or been in touch with them by phone or letter in the last month? Who?
53. Frequency of Contact (Friends)

1 = 2 or more times a week
4 = Only one contact reported during month
5 = Not at all during the last month
9 = Not able to identify any friends
54. Communication
During the last month, have you been able to talk easily with (one friend)? (specify).
What types of things did you talk about? Could you talk about your feelings and problems? Are there some things you
found it hard to talk about? Is this different than usual? Are there things you feel you should have talked about but
didn't?
54. Communication
1 = Almost always talks easily with at least one person
2 = Usually talks easily with at least one person
3 = Sometimes does and sometimes doesn't talk easily
4 = Usually doesn't talk easily
5 = Almost never talks easily
9 = No interpersonal contacts
24 of 30
55. Friction (Friends)
How have you been getting along with your friends in the last month? Are there things (they) did which annoyed you or
made you angry? IF YES: Did you hold your feelings in? Did the other person know you were upset? Are there things
you did which annoyed (them) or made (them) angry? Did you argue much? Have there been any open disagreements?
How often? How serious have those arguments been? Is there anyone you avoided because you knew you'd get into an
argument.

9 = Does not apply (no friends)
56. Sensitivity
Have any of your friends offended you or hurt your feelings in the past month? Tell me what happened.
IF YES: Have you been able to get over this?
ASK EVERYONE:
Is there anything that happened in the past that you still haven't been able to get over?
56. Sensitivity
1 = Has not felt hurt or offended
2 = Has felt hurt or offended once or twice but recovered quickly
3 = Has felt hurt or offended once or twice and recovered with difficulty
4 = Frequently felt hurt or offended
5 = Typically has felt hurt or offended over the last month
9 = Does not apply (no friends)
INTERVIEW ORDER OF FOLLOWING SECTIONS (XIII. SEXUAL ADJUSTMENT AND XIV PERSONAL
WELL-BEING) MAY BE REVERSED IF DESIRED.
25 of 30
XII. ROMANTIC INVOLVEMENT
ASK ONLY FOR PATIENTS NOT CURRENTLY LIVING WITH A CONJUGAL PARTNER (A
HOMOSEXUAL PARTNER IS ACCEPTABLE AS A CONJUGAL PARTNER).
d. WILL ROMANTIC ITEMS BE ASKED?
1=YES 2=NO
(IF NO, I. E., PATIENT HAS CURRENT CONJUGAL PARTNER,
SKIP TO SECTION XIII (SEXUAL ADJUSTMENT), P. 27.
57., 58., & 59.
Now I am going to ask how things are going for you in more intimate relationships.
Have you had any romantic interests the last month, you know a (boyfriend/girlfriend/companion)
or someone you just met?
IF YES. ASK: How often have you seen (him/her)? Is there anyone else you've seen? How often? Have you enjoyed
your time together? Any problems? Is breaking up a problem? How serious would you say these are?
IF NO, ASK: Would you like to meet someone? Is there a problem meeting someone? Is breaking up a problem?
57. Frequency of Romantic Contacts

4 = Only one contact reported during month
5 = Not at all during the last month
58. Interest
IF NO CONTACTS, SCORE ON BASIS OF INTEREST ALONE.
58. Interest
1 = Contacts are almost always pleasant and/or actively interested in contacts (involves effort)
2 = Contacts are often pleasant and/or often interested
3 = Tolerable and/or indifferent
4 = Often unpleasant and/or generally uninterested
5 = Contacts are almost always unpleasant and/or no interest in contacts
59. Communication
During the last month, have you been able to talk easily with (PARTNER)? (specify).
What types of things did you talk about? Could you talk about your feelings and problems? Are there some things you
found it hard to talk about? Is this different than usual? Are there things you feel you should have talked about but
didn't?
59. Communication
1 = Almost always talks easily with partner
2 = Usually talks easily with at least one person
3 = Sometimes does and sometimes doesn't talk easily
4 = Usually doesn't talk easily
5 = Almost never talks easily
9 = No partner
26 of 30
How have you been getting along with your partner in the last month? Are there things (they) did which annoyed you or
made you angry? IF YES: Did you hold your feelings in? Did the other person know you were upset? Are there things
you did which annoyed (them) or made (them) angry? Did you argue much? Have there been any open disagreements?
How often? How serious have those arguments been? Is there anyone you avoided because you knew you'd get into an
argument.
60. Friction (partner)

9 = Does not apply (no partner)
61. Problems (Romance)

1 = Almost never has problems in meeting or sustaining contacts
2 = Sometimes has problems
3 = Often has problems
4 = Very often has problems
5 = Almost always has problems in meeting or sustaining contacts (would like contacts but has none)
27 of 30
XIII. SEXUAL ADJUSTMENT
62-64. ASK FOR EVERYONE Have you been interested in having sex during the last month? Have you had sexual
intercourse during the last month? What about self-pleasuring or masturbation?
IF YES: How often? Is that a change for you? Has it been less often when you've been upset or not feeling well? Has it
been satisfying to you? Any problems? How serious would you say these are?
IF NO: Is there any problem? During the last month, has there been a change in how often you've had sex?
62. Interest
FOR PATIENTS COMPLETELY INACTIVE DURING THE TIME PERIOD, SCORE ON BASIS OF INTEREST
ALONE
62. Interest
1 = Pleasant and/or actively interested
2 = Often pleasant and/or often interested
3 = Tolerable and/or uninterested-indifferent
4 = Often unpleasant and/or generally uninterested
5 = Unpleasant and/or no interest
63. Frequency
4 = Only once during month
5 = Not at all
64. Problems
1 = Almost never has problems
2 = Sometimes has problems and/or experiences difficulties
3 = Often has problems and/or experiences difficulties
4 = Very often has problems and/or experiences difficulties
5 = Almost always has problems and/or experiences difficulties or complete avoidance in
anticipation of difficulties
9 = Does not apply--no contacts
28 of 30
XIV. PERSONAL WELL BEING
ASK FOR EVERYONE
65. Physical Health and Care
How has your physical health been in the last month? Have you been taking care of yourself? Like eating regularly,
getting enough sleep, exercise, smoking, physical and dental checkups? Any problems with (chronic medical
condition)? Down grade at lest one point for smoking or obesity
65. Physical Health and Care

1 = Attempts to maintain optimal health
2 = Moderate concern for health but not doing everything possible
3 = No apparent neglect but no active concern about health
4 = Some signs or reports of neglected health
5 = Many signs or reports of neglected health
66. Personal Appearance and Grooming
RATE ON BASIS OF APPEARANCE AND APPARENT CONCERN.
IF NECESSARY TO RATE, ASK : During the past month, has anyone helped you choose your clothes? Who saw to it
that you had clean clothes? Did (someone) lay out your clothes in the morning?
66. Personal Appearance and Grooming

1 = Particularly well groomed
2 = Reasonably neat, clean and appropriate
3 = Reasonable appearance, but responsibility borne by someone else or a little unkempt
4 = Some signs of neglect or bizarre or inappropriate appearance
5 = Un-kept, dirty, signs of extreme neglect
67. Loneliness
Have you felt lonely this last month? Have you felt cut off or left out by your family or friends? Have there been times
when you wished you could be closer to a certain friend or someone in the family?
67. Loneliness
1 = Has not felt lonely
2 = Has felt a little lonely sometimes
3 = Has felt a little lonely frequently
4 = Has felt very lonely occasionally or frequently
5 = Feels totally alone (even in the presence of others)
29 of 30
68. Self Appraisal
In looking over the way things have been going the last month, in general, how satisfied, content, or happy have you
been?
68. Self Appraisal

1 = Extremely happy, satisfied, content
2 = Moderately happy, satisfied, content
3 = Indifferent or bored or unable to express or verbalize feelings or fluctuating feelings
4 = Moderately unhappy, dissatisfied, discontent
5 = Extremely unhappy, dissatisfied, discontent
Is there anything else you want to tell me? Do you want to ask me any questions?
XV. GLOBALS
RATE GLOBAL ITEMS IMMEDIATELY AFTER THE INTERVIEW. USE ALL AVAILABLE INFORMATION
SUPPLIED BY PATIENT AS WELL AS INFORMATION WHICH MAY NOT HAVE BEEN SPECIFICALLY
RELEVANT TO THE INDIVIDUAL ITEMS. RATE RAPIDLY ON GENERAL IMPRESSIONS. INCLUDE NON
SPECIFIC ASPECTS OF THE PATIENT'S BEHAVIOR IN THE INTERVIEW SITUATION--NON-VERBAL CUES,
SUSPECTED DENIAL. INSIGHT DEFICIENCY, ETC. IN MAKING JUDGMENTS, COMPARE PATIENT TO
COMMUNITY NORMS AND STANDARDS, NOT TO WHAT YOU MAY KNOW OF HIS EARLIER
ADJUSTMENT OR TO OTHER FORMER PATIENTS.
SCALE POINTS FOR ALL GLOBALS
1 = Excellent adjustment
2 = Very good adjustment
3 = Good adjustment
4 = Fair adjustment
5 = Poor adjustment
6 = Very poor adjustment
7 = Severe maladjustment
9 = Category not ratable
69. Instrumental Role Performance
CONSIDER CONSISTENCY AND EFFECTIVENESS OF WORK PERFORMANCE IN VIEW OF EDUCATION,

PRIOR TRAINING AND EXPERIENCE. INCLUDE ALL INSTRUMENTAL ROLES--WORKER, HOMEMAKER,
STUDENT AND CHORES--IF PATIENT HAS MULTIPLE ROLES. IF THE PERSON IS WORKING IN ANY TYPE
OF SETTING, SCORE A MAXIMUM OF 5. IF SETTING IS COMPETITIVE WORK OR THE INDIVIDUAL IS
CARING FOR SOMEONE ELSE ADEQUATELY (A CHILD, ILL PARENT), SCORE A MAXIMUM OF 4.
UNEMPLOYED BUT LOOKING FOR WORK WOULD RATE A 6; NO INTEREST IN WORK AND
UNEMPLOYED WOULD BE A 7, UNLESS ASSUMING MAJOR RESPONSIBILITY FOR OTHER ROLES
70. Principal Family Member/Household
CONSIDER DEGREE OF INTEGRATION WITH PRINCIPAL FAMILY MEMBER AND OTHERS IN

HOUSEHOLD IN TERMS OF MUTUAL SUPPORT, AFFECTION AND PARTICIPATION. IF THE PERSON HAS
NO IMMEDIATE FAMILY, SCORE A 9. IF THE PERSON HAS ONGOING POSITIVE CONTACT WITH AT
LEAST ONE FAMILY MEMBER, SCORE A MAXIMUM OF 5.
30 of 30
71. Extended Family
CONSIDER DEGREE OF RELATIONSHIP WITH EXTENDED FAMILY IN TERMS OF MUTUAL SUPPORT,

AFFECTION, AND PARTICIPATION. IF NO EXTENDED FAMILY ALIVE, RATE “9”. IF NO CONTACT WITH
LIVING EXTENDED FAMILY, RATE HIGHER.
72. Social/Leisure
CONSIDER BOTH LEVEL OF AND QUALITY OF ACTIVITIES AND MEANINGFULNESS OF FRIEND AND
ACQUAINTANCE RELATIONSHIPS. INCLUDE LEISURE ACTIVITIES. IF THE PERSON HAS AT LEAST
TWO FRIENDS, SCORE A MAXIMUM OF 5.
73. Intimate Interpersonal Relations
CONSIDER ROMANTIC / SEXUAL / PARTNER RELATIONSHIPS. STATED INTEREST—SCORE A MAXIMUM

OF 6.
74. Personal Well-being
CONSIDER PATIENTS SENSE OF WELL-BEING AND SELF-CARE, EMPHASIZE PATIENT SELF-REPORT.
75. General Adjustment
CONSIDER PERFORMANCE IN ALL ROLES, INTERPERSONAL RELATIONSHIPS IN AND OUT OF THE

HOME, PERSONAL COMFORT AND SATISFACTION.
Rev.July30th, 2000
31 of 30
VOMI SOCIAL ADJUSTMENT SCALE
Patient Version
Patient Initial: __ __ __ Patient I.D. # Date: ________________
Rater Initial: __ __ __ ID#: __ __ __ Occasion:
Interview Outcome:
1- Interview Conducted Successfully 2- PT Declined Interview 3 – PT left study 4 – Other _______________________
GENERAL INSTRUCTIONS
TEXT IN UPPER CASE REPRESENTS INSTRUCTIONS TO THE INTERVIEWER.
TEXT IN BOTH UPPER AND LOWER CASE IS TO BE READ TO THE PATIENT.
PHRASES IN PARENTHESES SHOULD BE REPLACED BY TERM APPROPRIATE TO PERSON BEING

INTERVIEWED. FOR EXAMPLE--(date) "the first of the year"; (he) "your husband" "your cousin" "he".
ITALICIZED TEXT, Has anyone had to talk to you about your work? ARE PROBE QUESTIONS WHICH ONLY
NEED TO BE ASKED IF INSUFFICIENT INFORMATION IS PROVIDED BY THE LEAD QUESTIONS.
LEAD QUESTIONS MUST ALWAYS BE ASKED.
NON-SPECIFIC PROBES SUCH AS--Could you tell me more about that? Could you give me an
example/Anything else?--ARE ALWAYS IN ORDER.
IT IS ALSO ALWAYS PERMISSIBLE TO REPEAT WHAT THE PATIENT HAS SAID AS A QUESTION TO
ELICIT FURTHER INFORMATION.
OTHER THAN THESE NON-SPECIFIC PROBES, OTHER QUESTIONS SHOULD BE MINIMIZED.
DEFINED ANCHOR POINTS FOR EACH ITEM ARE SET OFF BETWEEN LINES AND NUMBERED. ONLY THE
NUMBERS ARE TO BE ENTERED ON THE RECORDING SHEET.
IF NECESSARY, PHRASES FROM CATEGORIES MAY BE READ TO PATIENT. ALWAYS READ AT LEAST
TWO CATEGORIES AND ALTERNATE ORDER, I.E, HIGHER OR LOWER FIRST.
1 of 30

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SOCIAL ADJUSTMENT SCALE-II

Patient Name: Patient I.D. # _____________ Date: ________________

Rater Initial: _____________ Assessment:

TEXT IN UPPER CASE REPRESENTS INSTRUCTIONS TO THE INTERVIEWER.

TEXT IN BOTH UPPER AND LOWER CASE IS TO BE READ TO THE PATIENT.

PHRASES IN PARENTHESES SHOULD BE REPLACED BY TERM APPROPRIATE TO PERSON BEING

LEAD QUESTIONS MUST ALWAYS BE ASKED.

OTHER THAN THESE NON-SPECIFIC PROBES, OTHER QUESTIONS SHOULD BE MINIMIZED.

I. INSTRUMENTAL ROLE DETERMINATION

WHICH INSTRUMENTAL ROLES) WILL BE EVALUATED?

2. Working Status (RECORD ONLY ONE)

3. Number of scheduled work hours per week

4. Time Lost (Work)

5. Performance Adequacy (Work)

RATE DESCRIBED IMPAIRMENT, NOT PERSONAL FEELINGS. OTHERS WOULD BE LIKELY TO

5. Performance Adequacy (Work)

RATE PATIENT'S SUBJECTIVE FEELINGS ABOUT PERFORMANCE.

6. Feelings of Adequacy (Work)

RATE OVERT BEHAVIOR INCLUDING EXPRESSED FEELINGS OF ANGER, ARGUMENTS, OVERT

ASK ONLY IF NEEDED TO RATE

RATE PATIENTS FEELINGS.

9. & 10. Affect (Work)

What did you like about your (work)?

10. Interest (Work)

11. Desire for Work

12. Homemaker Status (RECORD ONLY ONE)

13. Time Lost (Homemaker) and

14. Performance Adequacy (Homemaker)

RATE EACH AREA AND AVERAGE:

13. Time Lost (Homemaker)

15. Feelings of Adequacy (Homemaker)

16. Friction (Homemaker)

RATE OVERT BEHAVIOR INCLUDING EXPRESSED FEELINGS OF ANGER, ARGUMENTS, OVERT

16. Friction (Homemaker)

ASK ONLY IF NEEDED TO RATE

RATE PATIENTS FEELINGS.

17. Distress (Homemaker)

18. & 19. Affect (Homemaker)

18. Likes (Homemaker)

19. Interest (Homemaker)

20. Student Status

21. Time Lost (Student)

21. Time Lost (Student)

22. Performance Adequacy (Student)

How have you been doing in your schoolwork?

22. Performance Adequacy (Student)

23. Feelings of Adequacy (Student)

24. Friction (Student)

RATE OVERT BEHAVIOR INCLUDING EXPRESSED FEELINGS OF ANGER, ARGUMENTS, OVERT

24. Friction (Student)

ASK ONLY IF NEEDED TO RATE

25. Distress (Student)

26. & 27. Affect (Student)

26. Likes (Student)

27. Interest (Student)

28. Performance Adequacy (Chores)

28. Performance Adequacy (Chores)

29. Feelings of Adequacy (Chores)

29. Feelings of Adequacy (Chores)

30. Friction (Chores)

30. Friction (Chores)

31. Distress (Chores)

ASK ONLY IF NEEDED TO RATE

Patient Name: Patient I.D. # _ Date: ____

Patient Initial: Patient I.D. # Date: ______________

Rater Initial: ID#: Occasion: