Symptom Checklist

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Please note that the symptoms on the right are not an exhaustive list of psychological symptoms that you might be experiencing. You may be experiencing something that is different from what is on this list, but still is significantly troubling for you.

If you feel you are in imminent danger or hurting yourself or someone else, please call 911 or go to your nearest Emergency Room or psychiatric hospital.

Symptom Checklist

Are you currently feeling suicidal

Suicidal thoughts?
Plan?
Means available?
Do you intend to carry this out?

Are you currently feeling homicidal?

Homicidal thought?
Plan?
Means available?
Do you intend to carry this out?

How long have you been experiencing the problems you are currently experiencing?

less than a month
3 months or more
6 months or more
1 year or more

Because of how you are feeling, have you experienced a significant decline in functioning at school or socially?

Do you currently have any medical conditions?

Lately, have you experienced any of the following during the same 2 week period?

Do you feel depressed most of the day, nearly every day?
Do you feel like your interest is markedly diminished in all, or almost all activities of the day nearly every day?
Have you lost a significant amount of weight when not dieting, or have you had significant weight gain?
Do you experience insomnia or hypersomnia (sleeping too much) nearly every day?
Do you experience psychomotor agitation or retardation nearly every day?
Do you experience fatigue or loss of energy nearly every day?
Do you feel worthless? Do you experience excessive guilt nearly every day?
Have you noticed a diminished ability to think or concentrate, or indecisiveness, nearly every day?
Do you experience recurrent thoughts of death, recurrent suicidal ideation, a plan for suicide, or have you made a suicide attempt?
Have you recently experienced the death of someone close to you within the last 2 months?

Have any of the following symptoms lasted at least 1 week in duration?

Do you feel your self esteem is inflated, or do you have a sense of grandiosity?
Do you have a decreased need for sleep, feeling rested after only 3 hours of sleep?
Are you more talkative than usual, or feel pressured to keep talking?
Do you experience a flight of ideas, or feel like your thoughts are racing?
Are you easily distractable?
Have you experienced an increase in goal directed activity?
Have you experienced an excessive involvement on pleasurable activities that have a high potential for painful consequences?

Have you experienced any of the following?

Have you been exposed to a traumatic event or series of events that involved the threat of death or serious injury, and to which your response was intense fear, helplessness, or horror?
Have you ever experienced ever experienced a traumatic event which caused recurrent, intrusive, and distressing recollections, thoughts, dreams, feelings, associated with that event
Do you persistently avoid stimuli associated with a traumatic event from your past because exposure to such stimuli will cause significant disruptions in your daily life?
Have you noticed that following a traumatic event, you have experienced sleep difficulty, irritability, anger, difficulty concentrating, hypervigilance, or an exaggerated startle response?

Have you experienced any of the following?

Have you been experiencing excessive anxiety and worry, occurring more days than not, for the past 6 months?
Do you find it difficult to control your level of worry?
Do you find that anxiety or worry is associated with at least three or more of the following: restlessness or feeling on edge, easily fatigued, difficulty concentrating, irritability, muscle tension, and/or sleep disturbance?

Have you developed emotional or behavioral symptoms in response to an identifiable stressor occurring within the last 3 months, that are in excess of what would normally be expected from exposure to the stressor?

Have you experienced any of the following for at least 1 month in duration?

Do you experience recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated?
Do you experience persistent and excessive worry about losing, or about possible harm befalling, major attachment figures?
Do you experience excessive worry that an untoward event will lead to separation from a major attachment figure? (e.g. getting lost or being kidnapped)
Do you experience persistent reluctance or refusal to go to school or eslewhere because of fear of separation?
Do you experience persistently and excessively fearful, or reluctant to be alone or without major attachment figures at home or without significant adults in other settings?
Do you experience reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home?
Do you experience repeated nightmares involving the theme of separation?
Have you noticed repeated complaints or physical symptoms (such as headaches, stomachaches, nausea, or vomitting) when separation from major attachment figure occurs or is anticipated?

Have you noticed any of the following?

Often losing temper?
Often arguing with adults?
Often actively defying or refusing to comply with adults' requests or rules?
Often deliberately annoying people?
Often blame others for mistakes or misbehavior?
Often touchy or easily annoyed by people?
Often angry or resentful?
Often spiteful or vindictive?

In the last 12 months, have you done any of the following?

Been aggressive (e.g. bullying, threatening, initiating fights, used a weapon, physical cruelty, stealing while confronting, forced sexual activity) towards people or animals?
Destroyed property?
Been deceitful or lied to obtain goods or favors or to avoid obligations, or have they stolen or broken into someones house, building, or car?
Been guilty of serious rule violations such as staying out at night, running away at least twice, or truancy from school?

For the last 6 months, have you experienced any of the following?

Often fail to give close attention to details or make careless mistakes in schoolwork, work, or other activities?
Often have difficulty sustaining attention in tasks or play activities?
Often seem not to listen when spoken to directly?
Often not follow through on instructions and fails to finish school-work, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)?
Often have difficulty organizing tasks and activities?
Often avoid,dislike, or show reluctance to engage in tasks that require sustained mental effort (such as schoolwork or homework)?
Often lose things necessary for tasks or activities (e.g. toys, school assignments, pencils, books, or tools)?
Often easily distracted by extraneous stimuli?
Often forgetful in daily activities?

For the last 6 months, have you experienced any of the following?

Often fidget with hands or feet or squirms in their seat?
Often leave their seat in the classroom or in other situations in which remaining in their seat is expected?
Often run about or climb excessively in situations in which it is innapropriate?
Often have difficulty playing or engaging in leisure activities quietly?
Often seem “on the go” or often act as if “driven by a motor?”
Often talk excessively?
Often blurt out answers before questions have been completed?
Often have difficulty awaiting their turn?
Often interrupt or intrude on others?

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