|
Please
rate all of the following behaviors during the period since your last
appointment. |
|
N=
Never, S= Sometimes, O=Often, A=Almost Always |
|
1. Use of alcohol or recreational drugs |
N |
S |
O |
A |
|
|
|
2. Aggression (hitting. kicking, pushing, threatening, etc.) |
N |
S |
O |
A |
|
|
|
3. Hurting yourself (cutting or burning skin, attempting
suicide) |
N |
S |
O |
A |
|
|
|
4. Defiance of authority at home, school, or work |
N |
S |
O |
A |
|
|
|
5.
Difficulties focusing on tasks, trouble getting things done,
distractible |
N |
S |
O |
A |
|
|
|
6. Physical restlessness, fidgeting, hyperactivity |
N |
S |
O |
A |
|
|
|
7. Antisocial/delinquent behaviors (lying to con others,
stealing, vandalism, etc.) |
N |
S |
O |
A |
|
|
|
8. Depressed moods (sad, low, negative, can’t have fun,
crying spells) |
N |
S |
O |
A |
|
|
|
9. Low energy, fatigue, tiredness |
N |
S |
O |
A |
|
|
|
10. Irritable moods, grouchy, over-reactive to stress |
N |
S |
O |
A |
|
|
|
11. Moody: moods change quickly without any clear
reason |
N |
S |
O |
A |
|
|
|
12. Elevated moods: too happy, giddy, or low
inhibitions lasting more than hours |
N |
S |
O |
A |
|
|
|
13. Too much energy (taking on too many projects, unable to
relax) |
N |
S |
O |
A |
|
|
|
14. Sleep: difficulty falling or staying asleep |
N |
S |
O |
A |
|
|
|
15. Sleep: sleeping too many hours |
N |
S |
O |
A |
|
|
|
16. Sleep: able to get by on very little sleep without
really missing it |
N |
S |
O |
A |
|
|
|
17. Low appetite or weight loss |
N |
S |
O |
A |
|
|
|
18. High appetite or weight gain |
N |
S |
O |
A |
|
|
|
19. Anxiety: worrying too much, can’t relax, feeling tense
or scared |
N |
S |
O |
A |
|
|
|
20. Anxiety: obsessive, unwelcome thoughts that you can’t get
off your mind |
N |
S |
O |
A |
|
|
|
21. Anxiety: compulsive rituals that you must do to feel
better |
N |
S |
O |
A |
|
|
|
22. Anxiety: panic attacks (suddenly feeling terrified,
overwhelmed, sick) |
N |
S |
O |
A |
|
|
|
23.
Anxiety: fearful of being in public or being around
other people |
N |
S |
O |
A |
|
|
|
24. Anxiety: memories of earlier bad experiences intruding
on daily life |
N |
S |
O |
A |
|
|
|
25. Memory problems (forgetting important things, confusion,
disorientation) |
N |
S |
O |
A |
|
|
|
26. Hearing voices or seeing visions that no one else can |
N |
S |
O |
A |
|
|
|
27. Strong beliefs or worries that other people say can’t be
true |
N |
S |
O |
A |
|
|
|
28. Thoughts confused, speech that doesn’t make sense |
N |
S |
O |
A |
|
|