COUPLE & FAMILY INSTITUTE OF TRI-CITIES AMEN ADULT GENERAL SYMPTOM CHECKLIST
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1 COUPLE & FAMILY INSTITUTE OF TRI-CITIES AMEN ADULT GENERAL SYMPTOM CHECKLIST Please rate yourself on each symptom listed below. Please use the following scale: Never Rarely Occasionally Frequently Very Frequently 1. depressed or sad mood 2. decreased interest in things that are usually fun, including sex 3. significant weight gain or loss, or marked appetite changes, increased/decreased. 4. recurrent thoughts of death or suicide 5. sleep changes, lack of sleep or marked increase in sleep 6. physically agitated or slowed down 7. low energy or feelings of tiredness 8. feelings of worthlessness, helplessness, hopelessness or guilt 9. decreased concentration or memory 10. periods of an elevated, high or irritable mood 11. periods of a very high self-esteem or grandiose thinking 12. periods of decreased need for sleep without feeling tired 13. more talkative than usual or pressure to keep talking 14. racing thoughts or frequent jumping from one subject to another 15. easily distracted by irrelevant things 16. marked increase in activity level 17. excessive involvement in pleasurable activities that have the potential for painful consequences (spending money, sexual indiscretions, gambling, foolish business) 18. panic attacks, which are periods of intense, unexpected fear or emotional discomfort (list number per month ) 19. periods of feeling dizzy, faint, or unsteady on your feet Rev date
2 21. periods of heart pounding or rapid heart rate 22. periods of trembling or shaking 23. periods of sweating 24. periods of choking 25. periods of nausea or abdominal upset 26. feelings of a situation not being real 27. numbness or tingling sensations 28. hot or cold flashes 29. periods of chest pain or discomfort 30. fear of dying 31. fear of going crazy or doing something uncontrolled 32. avoiding everyday places for fear of having a panic attack or having to go with others in order to feel comfortable. 33. excessive fear of being judged or scrutinized by other people, which causes you to avoid or panic in everyday situations. 34. persistent, excessive phobia (heights, closed spaces, specific animals, etc) please list 35. recurrent bothersome thoughts, ideas or images which you try to ignore. 36. trouble getting stuck on certain thoughts, having same thought over and over 37. excessive or senseless worrying 38. others complain that you worry too much or get stuck on the same thoughts 39. compulsive behaviors that you must do or you feel very anxious, such as excessive hand washing, checking locks, or counting or spelling. 40. needing to have things done a certain way or you become very upset 41. others complain that you do the same things over and over to an excessive degree (such as cleaning or checking) 42. recurrent and upsetting thoughts of a past traumatic event (molest, accident, fire, etc.), please list Rev date
3 43. recurrent distressing dreams of a past upsetting event 44. a sense of reliving a past upsetting event 45. a sense of panic or fear to events that resemble an upsetting past event. 46. you spend effort avoiding thoughts or feelings associated with a past trauma 47. persistent avoidance of activities or situation that cause you to remember a past upsetting event 48. inability to recall an important aspect of a past upsetting event 49. marked decreased interest in important activities 50. feeling detached or distant from others 51. feeling numb or restricted in your feelings 52. feeling that your future is shortened 53. quick startle 54. feel like you re always watching for bad things to happen 55. marked physical response to events that remind you of a past upsetting event, i.e., sweating when getting a car if you had been in a car accident. 56. marked irritability or anger outbursts 57. unrealistic or excessive worry in at least a couple areas of your life 58. trembling, twitching or feeling shaky 59. muscle tension, aches or soreness 60. feelings of restlessness 61. easily fatigued 62. shortness of breath or feeling smothered 63. heart pounding or racing 64. sweating or cold clammy hands 65. dry mouth 66. dizziness or lightheadedness 67. nausea, diarrhea or other abdominal distress 68. hot or cold flashes 69. frequent urination 70. trouble swallowing or lump in throat 71. feeling keyed up or on edge 72. quick startle response or feeling jumpy 73. difficulty concentrating or mind going blank 74. trouble falling or staying asleep 75. irritability Rev date
4 76. trouble sustaining attention or being easily distracted 77. difficulty completing projects 78. feeling overwhelmed by the tasks of everyday living 79. trouble maintaining an organized work or living area 80. inconsistent work performance 81. lacks attention to detail 82. makes decisions impulsively 83. difficulty delaying what you want, having to have your needs met immediately 84. restless, fidgety 85. make comments to others without considering their impact 86. impatient, easily frustrated 87. frequent traffic violations or near accidents 88. refusal to maintain body weight above a level most people consider healthy 89. intense fear of gaining weight or becoming fat even though underweight 90. feelings of being fat, even though you are underweight 91. recurrent episodes of binge eating large amounts of food 92. a feeling of lack of control over eating behavior 93. engage in regular activities to purge binges, such as self-induced vomiting, laxative use, diuretics, strict dieting or strenuous exercise 94. persistent over concern with body shape and weight 95. involuntary physical movement or vocal tics 96. delusional or bizarre thoughts (thoughts you know others would think are false) 97. seeing objects, shadows or movements that are not real 98. hearing voices or sounds that are not real 99. periods of time where your thoughts or speech are not connected or do not make sense to you or others 100. social isolation or withdrawal 101. severely impaired ability to function at home or at work Rev date
5 102. peculiar behaviors 103. lack of personal hygiene or grooming 104. inappropriate mood for the situation (i.e., laughing at sad events) 105. marked lack of initiative 106. frequent feelings that someone or something is out to hurt you or discredit you periods of extreme irritability, physical or verbal aggression or rage with little provocation 108. periods of confusion 109. periods of spaciness or missing brief periods of time 110. periods of fearfulness for no apparent reason 111. periods of de ja vu (the feeling that you ve been somewhere or experienced something before even though you never have) 112. periods of unusual visual (seeing) or auditory (hearing) sensations or illusions 113. periods of forgetfulness or memory problems 114. do you snore loudly ( or do others complain about your snoring) 115. have others said you stop breathing when you sleep 116. do you feel fatigued or tired during the day 117. do you often feel cold when others feel warm 118. do you often feel warm when others feel fine or they are cold 119. do you have problems with brittle or dry hair 120. do you have problems with dry skin 121. do you have problems with sweating 122. do you have problems with chronic anxiety or tension Rev date
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