Dr. Tom R.

Hawkins
PO Box 479
Grottoes, VA 24441-0479
540-249-9119

DID Screening Sheet

Symptoms of Dissociative Identity Disorder
(Multiple Personality Disorder)

Note: This lecture presentation and response sheet is for educational purposes only and should not be taken
as a clinical diagnosis. Results need to be confirmed by professionals qualified in your state.

For each yes answer, put the indicated percentage on the line to the left. Clinical title can be
found in the full handout with this lecture or the manual, Breaking the Chains of DID.

A._____________
____1. (17%) Do you have difficulties with insomnia, sleepwalking, traumatic nightmares,
and/or night terrors?
2. (17%) Do you have intrusive thoughts or imagery of traumatic events repeatedly
coming into your mind during the day?
___3. (17%) Do you tend to startle easily, over-react emotionally or feel numbed out?

___4. (17%) Are you easily overwhelmed or have difficulty staying focused on a task or
conversation?
___5. (17%) Do you seem to have an unusual number of physical symptoms which may
lack a known cause?
____6. (17%) Do you consider yourself accident prone or find yourself repeatedly in
abusive relationships or in other ways bringing harm to yourself or others?

____% Sum total of percentages for A.

B. ______________
___1. (14%) As you think about your life, has there been a prolonged period of time
during which you felt you were under the strong domination or control of
another person or group of persons?
___2. (14%) Do your emotions sometimes seem out of control resulting in any of the
following:
Persistent unpleasant feelings or depression
Chronic suicidal preoccupation
Self-injury
Explosive or extremely inhibited anger (may alternate)
Compulsive or extremely inhibited sexuality (may alternate)?
___3. (14%) Do you find yourself experiencing any of the following:
Periods of amnesia or gaps in consciousness and/or memory
Times of unusually vivid recall of traumatic events
Episodes of trance-like states
Times of feeling unreal or that the world is unreal
Reliving past experiences or being preoccupied with mentally rehearsing
them?
___4. (14%) Does your sense of self alternate with times of feeling any of the following:
Totally helpless or paralyzed in being able to act on your own
Intense shame, guilt and self-blame
Sense of being defiled or bearing a negative stigma
Completely different from others (may include sense of specialness, utter
aloneness, belief no other person can understand, or non-human identity)
___5. (14%) Does the way you view your perpetrator alternate to include any of the
following:
Preoccupation with relationship with perpetrator (includes preoccupation with
revenge)
Unrealistic attribution of total power to perpetrator (caution: victims
assessment of power realities may be more realistic than clinicians)
Idealization or undeserved gratitude
Viewing perpetrator as extremely special or even as god
Rationalization or acceptance of perpetrators belief system?
___6. (14%) Do you have problems relating to others, such as:
Isolation and withdrawal
Avoidance of, or inability to maintain, intimate relationships
Repeated search for rescuer
Persistent distrust
Repeated failures of self-protection
___7. (14%) Do you have alterations in major belief systems, such as:
Faith in God
Purpose in life
Worldview

____% Sum total of percentages for B.

C. ____________________
___1. (17%) Do you have little or no memories of the events of your childhood?
___2. (17%) Are their significant events in your life, even as an adult, for which you have
no memory?
___3. (17%) Do you find yourself frequently experiencing any of the following:
Staring off into space or being lost in deep thought
Losing the train of thought in conversation
Having a wandering mind
Losing concentration while listening?
___4. (17%) Do you find yourself experiencing any of the following:
Inconsistencies in perspective, feelings and logic
Changes in habits, handedness, or handwriting
Use of the pronoun we or us when speaking of self?
___5. (17%) Do you hear voices, arguments or unusually loud thoughts inside your
head?
___6. (17%) Do you find yourself easily losing touch with your physical surroundings or
feel like you could be easily hypnotized?

____% Sum total of percentages for C.

D. ________________
___1. (100%) Do you exhibit any of the following:
Extreme mood swings
Depression (may be intermittent)
Episodes of explosive anger
Unusual or exaggerated fears
Consistent anxiety
Inability to feel emotions or cry
Display of inappropriate emotions (for example, laughing when crying would
be a normal cultural response to a situation like at a funeral)?
____% Sum total of percentages for D.
E. ________________________
___1. (25%) Do you have frequent headaches?

___2. (25%) Do you have pain or other physical symptoms for which there seems to be no
medical cause?

___3. (25%) Do you have medical symptoms which are present some times but not at
others, such as:
Need for glasses
Allergies
Blood sugar and need for insulin
___4. (25%) Have you ever had bruises, welts, scratches, burns, pain or sensations of
touch or pressure that cannot be explained by current experience?

______% Sum total of percentages for E.

F. __________________________
___1. (20%) Have you ever had an eating disorder or severe disruption in normal eating
habits, such as:
Refusing to eat normal amounts of food
Consistent overeating
Binging
Purposely inducing vomiting
Taking inordinate amounts of laxatives?
___2. (20%) Have you ever struggled with consistent or intermittent addictive behaviors,
such as:
Alcohol,
Drugs
Sex
Food
Gambling
Work?
___3. (20%) Have you ever thought about, or tried to, commit suicide or purposely injure
your body?
___4. (20%) Do you ever experience any of the following:
Repeated failures in schooling, jobs and relationships in spite of feeling
capable
Functioning well externally but feeling like you are falling apart inside
Feeling an inconsistent ability to function in various aspects of life
Feeling generally unable to pull life together?
__ 5. (20%) Has your ability to function decreased seemingly without cause?

_____% Sum total of percentages for F.

G. _____________
___1. (12.5%) Have you experienced any unexplained fluctuation in your intellectual and
creative skills?
___2. (12.5%) Are you sometimes confused about whether something just happened or
took place days or weeks ago?
___3. (12.5%) Have you ever seemed to acquire or lose possessions without conscious
knowledge?
___4. (12.5%) Are you frequently accused of saying or doing things you do not feel you have
said or done?
___5. (12.5%) Do you have any abnormal fears which you may hesitate to admit?
___6. (12.5%) Do you have pictures of traumatic events flash in your mind while fully
awake for which you have no conscious memory?
___7. (12.5%) Have you ever found yourself suddenly remembering strange behaviors by
friends or family members which seemingly make no sense?
___8. (12.5%) Do you experience consistent or intermittent low self-esteem?

_________ % Sum total of percentages for G.

Add sum totals: A. ______

B. ______
A score of 30% or more occurring in
C. ______ most of the 7 areas may indicate the
D. ______ possibility of DID. However, this
should be confirmed by a qualified
E. ______
professional.
F. ______
G. ______
______ % Total

% Total ______ 7 = ___________ SCORE

(Sum total of percentages divided by 7 = Score)