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1 = sad, tired, anxious, tense, irritable, withdrawn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