Choice Psychiatric Healthcare | Symptom Assessment Form

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Forms

Branches
Resources
Testimonies
Contact/Video

Symptom Assessment

Instructions:

First and Last Name *

Email *

Date of Birth *

The questions below ask about things that might have bothered you. For each question, choose the number that best describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS.

0 = None (Not at all) 1 = Slight (Rare, less than a day or two) 2 = Mild (Several days) 3 = Moderate (More than half the days) 4 = Severe (Nearly every day)

1. Little interest or pleasure in doing things?

0
1
2
3
4
No elements found. Consider changing the search query.
List is empty.

2. Feeling down, depressed, or hopeless?

0
1
2
3
4
No elements found. Consider changing the search query.
List is empty.

3. Feeling more irritated, grouchy, or angry than usual?

0
1
2
3
4
No elements found. Consider changing the search query.
List is empty.

4. Sleeping less than usual, but still have a lot of energy?

0
1
2
3
4
No elements found. Consider changing the search query.
List is empty.

5. Starting lots more projects than usual or doing more risky things than usual?

0
1
2
3
4
No elements found. Consider changing the search query.
List is empty.

6. Feeling nervous, anxious, frightened, worried, or on edge?

0
1
2
3
4
No elements found. Consider changing the search query.
List is empty.

7. Feeling panic or being frightened?

0
1
2
3
4
No elements found. Consider changing the search query.
List is empty.

8. Avoiding situations that make you anxious?

0
1
2
3
4
No elements found. Consider changing the search query.
List is empty.

9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)?

0
1
2
3
4
No elements found. Consider changing the search query.
List is empty.

10. Feeling that your illnesses are not being taken seriously enough?

0
1
2
3
4
No elements found. Consider changing the search query.
List is empty.

11. Thoughts of actually hurting yourself?

0
1
2
3
4
No elements found. Consider changing the search query.
List is empty.

12. Hearing things other people couldn’t hear, such as voices even when no one was around?

0
1
2
3
4
No elements found. Consider changing the search query.
List is empty.

13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?

0
1
2
3
4
No elements found. Consider changing the search query.
List is empty.

14. Problems with sleep that affected your sleep quality over all?

0
1
2
3
4
No elements found. Consider changing the search query.
List is empty.

15. Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)?

0
1
2
3
4
No elements found. Consider changing the search query.
List is empty.

16. Unpleasant thoughts, urges, or images that repeatedly enter your mind?

0
1
2
3
4
No elements found. Consider changing the search query.
List is empty.

17. Feeling driven to perform certain behaviors or mental acts over and over again?

0
1
2
3
4
No elements found. Consider changing the search query.
List is empty.

18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?

0
1
2
3
4
No elements found. Consider changing the search query.
List is empty.

19. Not knowing who you really are or what you want out of life?

0
1
2
3
4
No elements found. Consider changing the search query.
List is empty.

20. Not feeling close to other people or enjoying your relationships with them?

0
1
2
3
4
No elements found. Consider changing the search query.
List is empty.

21. Drinking at least 4 drinks of any kind of alcohol in a single day?

0
1
2
3
4
No elements found. Consider changing the search query.
List is empty.

22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco?

0
1
2
3
4
No elements found. Consider changing the search query.
List is empty.

23. Using any of the following medicines ON YOUR OWN, that is, without a doctor’s prescription, in greater amounts or longer than prescribed [e.g., painkillers (like Vicodin), stimulants (like Ritalin or Adderall), sedatives or tranquilizers (like sleeping pills or Valium), or drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)]?