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1 = sad, tired, anxious, tense, irritable, withdrawn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: