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The PRIME Screen

This document appears to be a screening questionnaire for psychological experiences. It contains 12 statements about unusual sensory, psychological, emotional, and social experiences. Respondents are asked to indicate how much they agree or disagree with each statement based on their experiences in the past year, using a scale of 0 to 6. The statements include experiences such as feeling that unusual things are going on, predicting the future, feeling thoughts are being controlled, hearing voices, and being concerned about going crazy.

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137 views1 page

The PRIME Screen

This document appears to be a screening questionnaire for psychological experiences. It contains 12 statements about unusual sensory, psychological, emotional, and social experiences. Respondents are asked to indicate how much they agree or disagree with each statement based on their experiences in the past year, using a scale of 0 to 6. The statements include experiences such as feeling that unusual things are going on, predicting the future, feeling thoughts are being controlled, hearing voices, and being concerned about going crazy.

Uploaded by

saurav.das2030
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Version A July 2004 HIC 26895

The PRIME Screen


Pt. #. __________________ Date: _____/_____/_____ Office ID #: ________________

Please read the attached information sheet before completing this questionnaire.

The following screen asks about your personal experiences. We ask about your sensory, psychological, emotional, and social
experiences. Some of these questions may seem to relate directly to your experiences and others may not. Please answer all
questions.

Within the past year


Based on your experiences within the past year, please indicate how
much you agree or disagree with the following statements.

Please read each question carefully and circle the answer that best

DEFININTELY
describes your experiences.

SOMEWHAT

SOMEWHAT
DEFINITELY
DISAGREE

DISAGREE

DISAGREE

NOT SURE
SLIGHTLY

SLIGHTLY
AGREE

AGREE

AGREE
Please answer all questions.

I think that I have felt that there are odd or unusual things going on
1 0 1 2 3 4 5 6
that I can’t explain.

2 I think that I might be able to predict the future. 0 1 2 3 4 5 6

I may have felt that there could possibly be something interrupting or


3 0 1 2 3 4 5 6
controlling my thoughts, feelings, or actions.

I have had the experience of doing something differently because of


4 0 1 2 3 4 5 6
my superstitions.
I think that I may get confused at times whether something I
5 experience or perceive may be real or may be just part of my 0 1 2 3 4 5 6
imagination or dreams.
I have thought that it might be possible that other people can read
6 0 1 2 3 4 5 6
my mind, or that I can read other’s minds.

I wonder if people may be planning to hurt me or even may be about


7 0 1 2 3 4 5 6
to hurt me.

I believe that I have special natural or supernatural gifts beyond my


8 0 1 2 3 4 5 6
talents and natural strengths.

9 I think I might feel like my mind is “playing tricks” on me. 0 1 2 3 4 5 6

I have had the experience of hearing faint or clear sounds of people


10 0 1 2 3 4 5 6
or a person mumbling or talking when there is no one near me.

11 I think that I may hear my own thoughts being said out loud. 0 1 2 3 4 5 6

12 I have been concerned that I might be “going crazy”. 0 1 2 3 4 5 6

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