Form 2 Attachment D: FIBSER

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Attachment D: Frequency, Intensity, and Burden of Side Effects
Ratings (FIBSER)

Patient Name:_______________________

Date:______________

Frequency, Intensity, and Burden of Side Effects Ratings (FIBSER)
Instructions: Select the best response for the following three questions.

1.

Choose the response that best describes the frequency (how often) of the side effects of the medication
you have taken within the past week for your depression. Do not rate side effects if you believe they
are due to treatments that you are taking for medical conditions other than depression. Rate the frequency
of these side effects for the past week.

No Side
effects

Present 10%
of the time

0

1

2.

Present 25%
of the time

Present 50%
of the time

2

Present 75%
of the time

3

Present all
of the time

5

6

4

Choose the response that best describes the intensity (how severe) of the side effects that you believe are
due to the medication you have taken within the last week for your depression. Rate the intensity of the
side effect(s), when they occurred, over the last week.

No Side
Effects

Trivial

Mild

Moderate

Marked

0

1

2

3

4

3.

Present 90%
of the time

Severe

Intolerable

5

6

Choose the response that best describes the degree to which antidepressant medication side effects
that you have had over the last week have interfered with your day-to-day functions.

No
Impairment

Minimal
impairment

Mild
impairment

Moderate
impairment

Marked
impairment

Severe
impairment

Unable to
function

0

1

2

3

4

5

6

Citation: Wisniewski SR, Rush AJ, Balasubramani GK, Trivedi MH, Nierenberg AA: Self-rated
global measure of the frequency, intensity, and burden of side effects. Journal of
Psychiatric Practice 12:71-79, 2006

This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by
Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information
that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for
this collection of information is estimated to average 2 minutes per response, the estimated time required to complete
the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate
or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports
Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 5600 Fishers Lane, Room #07W42,
Rockville, MD 20857.