Symptom CheckList
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Symptom Checklist

This checklist is designed to help assess your full range of psychological functioning. Single symptoms might indicate a need for a medical or psychological consultation.  Clusters of symptoms suggests a need for further evaluation and treatment.

General Well-Being

_____ I am generally not very happy with my life.
_____ I am unable to relax or enjoy myself.
_____ Work/school is going terribly for me.
_____ I recently experienced an overwhelming life event.
_____ I am not functioning as well as in the past.
_____ My life is out of control.
_____ My relationships/social life is not what it should be
_____ I currently or recently have felt suicidal.

Depression

_____ sad _____ insomnia _____ loss interest in friends
_____ crying spells _____ waking early _____ loss interest in sex
_____ loss appetite _____ excessive sleep _____ easily fatigued
_____ weight loss _____ feel hopeless _____ suicidal thoughts

Anxiety

_____ nervous _____ jittery _____ heart palpitations
_____ mood swings _____ tension _____ temper outbursts
_____ irritability _____ worrying _____ persistent thoughts
_____ fatigue _____ tremble/shake _____ low concentration
_____ headaches _____ dizziness _____ stomach problems
_____ compulsions _____ weight loss _____ out of body experience
_____ difficulty with decisions _____ fear of going crazy

Substance Abuse Do you use any of the following?

_____ alcohol _____ marijuana _____ cocaine
_____ stimulants _____ hallucinogens _____ diuretics
_____ coffee _____ cigarettes _____ narcotics
_____ tranquilizers _____ diet pills

_____ I have occasionally thought about cutting down on substance use.
_____ Others have complained about my substance use.
_____ I have felt guilty or upset about my use.
_____ I have missed work/school due to my substance use.

Eating Disorder

_____ strict diets _____ vomiting _____ bingeing
_____ fasting _____ laxative use _____ constant eating
_____ over exercise _____ diuretic use _____ high sugar foods
_____ diet pills _____ ipecac use _____ food obsessing
_____ weight gain _____ weight loss _____ weight fluctuations
_____ overweight _____ unhappy with my appearances

Physical Symptoms

_____ stomach pains _____ back pain _____ arm, leg, joint pain
_____ menstrual pain _____ headaches _____ pain during sex
_____ chest pain _____ dizziness _____ fainting spells
_____ heart racing _____ skin rashes _____ shortness of breath
_____ low energy _____ constipation _____ diarrhea
_____ nausea _____ indigestion _____ low energy
_____ insomnia _____ nightmares _____ night awakenings
_____ exhaustion _____ hives _____ asthma

Relationships

_____ role conflict _____ resentments _____ insecure with family
_____ parenting fights _____ no sex _____ canít trust family
_____ money fights _____ little affection _____ frequent arguments
_____ considered counseling _____ not relaxed at home
_____ poor communication _____ considering divorce
_____ donít feel accepted _____ not enough time together
_____ jealousy in partner _____ not sexually satisfied
_____ angry with spouse _____ emotionally alone

Abuse

_____ physical abuse _____ sexual assault _____ been hit or kicked
_____ verbal abuse _____ have been raped _____ molested as child
_____ flashbacks _____ date raped _____ nightmares
_____ threatened w/ violence _____ sexually harassed
_____ pushed or choked _____ held at gun or knife point
_____ confronted with screaming and swearing

Loneliness


_____ usu. eat alone _____ no one to love _____ no groups
_____ few friends _____ few phone calls _____ donít see children
_____ not dating _____ no support group

Self-Esteem

_____ donít like self _____ perfectionist _____ not satis. w/ looks
_____ timid, shy _____ pessimistic _____ overly sensitive
_____ donít feel worthwhile _____ donít feel others will like me
_____ always doing for others _____ expect or fear rejection
_____ difficulty asking for needs to be met

 

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