Symptom Checklist

Patient’s Name:_______________________________________________________________

Evidenced By

(For Office Use Only)

Sad mood most of the day

Not interested in activities that used to be fun

Cannot fall asleep most of the time

Sleeps more than usual

Loss of energy

Does not spend as much time with friends as usual

Does not bathe or clean self regularly

Eats more or less than usual

Blames self

Acts angry much of the time

Acts unusually happy much of the time

At times needs little or no sleep

Exhibits sexual behavior

e.g. touching own or others privates

Talks so fast it is hard to understand

Tense, nervous, worries much of the time

Panic attacks: heart pounding, can’t breathe, sweating

Saw or had something bad or scary happen

Often remembers something bad or scary happening

Symptom Check List

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Parent category: Life