Obsessive Compulsive Survey Template

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Obsessive Compulsive Survey
Patient Name:
Date Completed:
Therapist Name:
Date Received:
Mood and Behaviors Over the Past 2 Weeks
Comments
1
I can’t keep myself from thinking about unpleasant things
1
2
3
4
5
2
I am obsessive when it comes to washing and cleanliness
1
2
3
4
5
I ask people to repeat their statements several times, even
3
1
2
3
4
5
when I understand them the first time
I think that if I touch other’s bodily fluids (sweat, blood, etc.)
4
1
2
3
4
5
my clothes or skin will become contaminated
I am afraid to use public toilets, sinks or transportation
5
1
2
3
4
5
because I think I will be contaminated
I rethink and review every interaction, conversation,
statement and gesture I made to make sure I didn’t do or say
6
1
2
3
4
5
something wrong
I hoard items that I don’t need and have trouble giving things
7
1
2
3
4
5
away
I have hoarded so many things that it impedes movement or
8
1
2
3
4
5
space in my home or office
I check doors, windows, locks, devices and drawers
9
1
2
3
4
5
repeatedly
I check stoves, switches, taps, lights, fans and outlets
10
1
2
3
4
5
repeatedly

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