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

=  sad, tired, anxious, tense, irritable, withdrawn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