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 _____ can’t trust family
_____ money fights _____ little affection _____ frequent arguments
_____ considered counseling _____ not relaxed at home
_____ poor communication _____ considering divorce
_____ don’t 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 _____ don’t see children
_____ not dating _____ no support group
Self-Esteem
_____ don’t like self _____ perfectionist _____ not satis. w/ looks
_____ timid, shy _____ pessimistic _____ overly sensitive
_____ don’t feel worthwhile _____ don’t feel others will like me
_____ always doing for others _____ expect or fear rejection
_____ difficulty asking for needs to be met
Why Therapy Press link
for articles about why to get treatment.
About Therapy Press link for
articles that explain more about therapy.
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