General Symptom Checklist printable pdf download

General Symptom Checklist

Please rate yourself on each of the symptoms listed below using the following scale. If possible, to give us the most

complete picture, have another person who knows you well (such as a spouse, partner, or parent) rate you as well. List the

other person ________________________. Please place a star by your most concerning symptoms.

Never

Rarely

Occasionally

Frequently

Very Frequently

Not Applicable

Other Self

____ ___ 1. Feeling depressed or being in a sad mood

____ ___ 2. Having a decreased interest in things that are usually fun

____ ___ 3. Experiencing a significant change in weight or appetite, increased or decreased

____ ___ 4. Having recurrent thoughts of death or suicide

____ ___ 5. Experiencing sleep changes, such as a lack of sleep or a marked increase in sleep

____ ___ 6. Feeling physically agitated or easily irritated

____ ___ 7. Having feelings of low energy or tiredness

____ ___ 8. Having feelings of worthlessness, helplessness, hopelessness or guilt

____ ___ 9. Experiencing decreased concentration or memory

____ ___ 10. Having periods of an elevated, high or irritable mood

____ ___ 11. Having periods of a very high self-esteem or grandiose thinking

____ ___ 12. Having periods of decreased need for sleep without feeling tired

____ ___ 13. Being more talkative than usual or feeling pressure to keep talking

____ ___ 14. Having racing thoughts or frequently jumping from one subject to another

____ ___ 15. Being easily distracted by irrelevant things

____ ___ 16. Having a marked increase in activity level

____ ___ 17. Excessive involvement in pleasurable activities that have the potential for painful

consequences (e.g., spending money, sexual indiscretions, gambling, foolish business ventures)

____ ___ 18. Experiencing panic attacks, which are periods of intense, unexpected fear

____ ___ 19. Having periods of trouble breathing or feeling smothered

____ ___ 20. Having periods of feeling dizzy, faint or unsteady on your feet

____ ___ 21. Having periods of heart pounding or rapid heart rate

____ ___ 22. Having periods of trembling or shaking

____ ___ 23. Having periods of sweating

____ ___ 24. Having periods of nausea or abdominal discomfort/trouble

____ ___ 25. Having feelings of a situation "not being real" or feeling as if you are in a movie

____ ___ 26. Experiencing numbness or tingling sensations

____ ___ 27. Experiencing hot or cold flashes

____ ___ 28. Having periods of chest pain or discomfort

____ ___ 29. Fearing death

____ ___ 30. Fearing going crazy or doing something out-of-control

____ ___ 31. Avoiding everyday places for 1) fear of having a panic attack or 2) needing to go with other

people in order to feel comfortable

____ ___ 32. Excessive fear of being judged by others, which causes you to avoid or get anxious in situations

____ ___ 33. Experiencing persistent, excessive phobia (heights, closed spaces, specific animals, etc.)

____ ___ 34. Having recurrent bothersome thoughts, ideas, or images that you try to ignore

____ ___ 35. Having trouble getting "stuck" on certain thoughts, or having the same thought over and over

____ ___ 36. Experiencing excessive worrying which feel irrational

____ ___ 37. Others complaining that you worry too much or get "stuck" on the same thoughts

____ ___ 38. Having compulsive behaviors that you must do or else you feel very anxious, such as excessive

hand washing, checking locks, or counting or spelling

General Symptom Checklist

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