Symptom Checklist

Print this page and fill out to track your moods.  Take this checklist with you when you see your doctor next.  Consider asking your family to help fill this out with you.

On a scale of one to ten, how do you feel? (circle the number)

1    2    3    4    5    6    7    8    9    10

1  =  sad, tired, anxious, tense, irritable, withdrawn
10 = happy, rested, relaxed, energized, involved in life

Check any words that describe how you have been feeling:

_ Trouble concentrating

_ Sad/Crying

_ Overeating/Not eating

_ Slept too much/Haven't been sleeping

_ Irritable/Angry/Worried/Anxious

_ Impulsive

_ Don’t care/Pessimistic

_ Racing thoughts/going a mile a minute

_ Lazy/No energy

_ Aches and pains

_ Guilty/Hopeless/Worthless/Overwhelmed

_ Difficult to concentrate or make decisions

_ Wanted to be alone

_ Reckless

_ Thoughts of death or suicide

_ Alcohol/Substance use

_ Other: ___________________________________________________________

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page created: May 4, 2006

page updated: August 25, 2006