symptom checklist

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SYMPTOM CHECKLIST Name: ______________________________________

Date: ______________________

Please circle the answer that describes the level you experience each of the following symptoms: Always

Often

Sometimes

Seldom

Never

Persistent feelings of sadness Crying spells Increased irritability Feelings of worthlessness Loss of interest in usual activities Outbursts of anger Insomnia - not able to sleep Unusual desire for sleep Decreased energy Poor concentration or indecision Loss of appetite Increased appetite Decrease in sex drive

Symptoms:

4 4 4 4 4 4 4 4 4 4 4 4 4

3 3 3 3 3 3 3 3 3 3 3 3 3

2 2 2 2 2 2 2 2 2 2 2 2 2

1 1 1 1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0 0 0 0

Mood swings Hyper behavior Out of control spending Increased sexual activity

4 4 4 4

3 3 3 3

2 2 2 2

1 1 1 1

0 0 0 0

Thoughts of suicide Self-mutilating thoughts or behaviors Violent behavior or thoughts

4 4 4

3 3 3

2 2 2

1 1 1

0 0 0

Anxiety or nervousness Phobias Fear of being alone Avoiding people or social situations

4 4 4 4

3 3 3 3

2 2 2 2

1 1 1 1

0 0 0 0

Obsessive thoughts or worries Feeling compelled to do certain things Unusual habits Intrusive negative or horrible thoughts

4 4 4 4

3 3 3 3

2 2 2 2

1 1 1 1

0 0 0 0

Low self-esteem Feelings of inferiority or shame Guilty conscience Loneliness Perfectionism Fear of rejection Sensitivity to criticism Jealousy Trouble getting along with others Problems at work

4 4 4 4 4 4 4 4 4 4

3 3 3 3 3 3 3 3 3 3

2 2 2 2 2 2 2 2 2 2

1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0

Fear of "going crazy" Suspiciousness Hallucinations Feeling of unreality

4 4 4 4

3 3 3 3

2 2 2 2

1 1 1 1

0 0 0 0

Headaches Stomach trouble Heart palpitations Chest pain Tingling or numbness Seizures or convulsions Dizziness or fainting spells Lack of quality sleep

4 4 4 4 4 4 4 4

3 3 3 3 3 3 3 3

2 2 2 2 2 2 2 2

1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0

Overeating Binging Purging Negative body image

4 4 4 4

3 3 3 3

2 2 2 2

1 1 1 1

0 0 0 0

Lustful thoughts Viewing pornography Sexual immorality Infidelity Compulsive masturbation

4 4 4 4 4

3 3 3 3 3

2 2 2 2 2

1 1 1 1 1

0 0 0 0 0

Alcohol abuse Illegal drug use Abuse of prescription drugs

4 4 4

3 3 3

2 2 2

1 1 1

0 0 0

Marital dissatisfaction Marital conflict Emotional distance Lack of sexual fulfillment

4 4 4 4

3 3 3 3

2 2 2 2

1 1 1 1

0 0 0 0