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Intrusive Thoughts and Repetitive Habits Self-Reflection

A non-diagnostic self-reflection on intrusive thoughts, repetitive behaviours and their impact over the past month.

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Healthcare · Mental health assessment. All Healthcare templates

Questions in this template

About You

  1. Thank you for taking part. These questions ask about unwanted thoughts and repeated habits you may have noticed during the past month. Your answers are confidential.

  2. This is a self-reflection, not a diagnosis. If these experiences are causing you distress, please speak to a doctor or mental health professional.

  3. How old are you?

    A number from 16 to 99

  4. What is your gender?

    Choose one:

    • Female
    • Male
    • Non-binary
    • Prefer not to say

Unwanted Thoughts

  1. During the past month, how often have you had each of these kinds of thoughts?

    • Worries about germs, dirt or illness that are hard to shake off
    • Fear that you might cause harm to someone, even though you do not want to
    • A strong need for things to be exactly right, even or symmetrical
    • Upsetting images or urges that pop into your mind against your will

    For each row: choose one:

    • Never
    • Rarely
    • Sometimes
    • Often
    • Very often

  2. On a typical day, how much time do these thoughts take up?

    Condition: Only when at least one kind of thought was reported

    Choose one:

    • Less than 1 hour
    • 1 to 3 hours
    • 3 to 8 hours
    • More than 8 hours

Repeated Actions

  1. During the past month, how often have you done each of these?

    • Washing or cleaning far more than needed
    • Checking things again and again, such as locks or switches
    • Counting, arranging or ordering things until they feel right
    • Repeating words or thoughts in your head to cancel out a bad thought

    For each row: choose one:

    • Never
    • Rarely
    • Sometimes
    • Often
    • Very often

  2. On a typical day, how much time do these actions take up?

    Condition: Only when at least one action was reported

    Choose one:

    • Less than 1 hour
    • 1 to 3 hours
    • 3 to 8 hours
    • More than 8 hours

  3. When you feel the urge to do one of these things, how often can you hold off or stop yourself?

    Condition: Only when at least one action was reported

    Choose one:

    • Always
    • Usually
    • Sometimes
    • Rarely
    • Never

Impact and Support

  1. Overall, how much distress do these thoughts or habits cause you?

    Choose one:

    • None
    • Mild
    • Moderate
    • Severe
    • Extreme

  2. How much do they get in the way of your work, studies or relationships?

    Choose one:

    • Not at all
    • A little
    • Moderately
    • A lot
    • Extremely

  3. Have you ever asked a professional for help with these thoughts or habits?

    Choose one:

    • Yes
    • No
    • Prefer not to say

  4. Would you like to receive information about where to find support?

    Choose one:

    • Yes
    • No

  5. Is there anything else you would like to share? (optional)

    Open answer