Symptom Checklist

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SYMPTOM CHECKLIST FOR CHILDREN & ADOLESCENTS NAME:___________________________________

DATE:________________________

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

Always

Often

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 friendships

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 Provocative behavior

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 functions

4 4 4 4

3 3 3 3

2 2 2 2

1 1 1 1

0 0 0 0

Page 1 of 2

Sometimes

Seldom

Never

Symptoms

Always

Often

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 school

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 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

4 4

3 3

2 2

1 1

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

Page 2 of 2

Sometimes

Seldom

Never