Barry F. Moss, Ph.D., Licensed Clinical Psychologist
Symptom Checklist
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Name:
 
Date:

CIRCLE OR HIGHLIGHT ANY OF THE FOLLOWING SYMPTOMS THAT APPLY TO YOU:

Headaches; dizziness; fainting spells; racing heart; shortness of breath; feeling of choking; chest pain; nausea; dizziness; stomach trouble; no appetite; increased appetite; weight gain in the last month, weight loss in the last month, fatigue; nightmares; alcoholism; feel tense; anger irritability; panicky; tremors; sweating; fear of losing control; fear of going crazy; fear of dying; anxious, trembling; feel in a "daze"; unwanted repetitive thoughts; avoidance of crowded places, unwanted repetitive habits; difficulty falling asleep; difficulty remaining asleep; awakening earlier than intended; difficulty waking up; sleeping for long periods

experienced or witnessed a life threatening event or serious injury; experienced fear, hopelessness or horror during the event; distressing recollections of the event; distressing dreams of the event; acting or feeling as if the event is recurring; difficulty talking about the event; difficulty seeing anything that reminds you about the event

depressed; suicidal ideas; past suicide attempts; feeling detached from others; feeling void of emotions; drug use; unable to relax; sexual problems; less interest in pleasant activities; unable to enjoy self; not like weekends or vacations; difficulty with decision making; inferiority feelings; lack of interest in doing things; feeling helpless; feel hopeless; feel like there is no future for you; guilt; memory or concentration difficulty; crying spells; unable to control anger; low energy; mood swings;

over_ambitious; shy; feel lonely; money problems; can't keep a job; difficulty keeping friends; difficulty with romantic relationships; bad home conditions; work stress; paranoia; hear voices; food binging; food purging; legal problems; constantly on guard for anything dangerous that could happen

difficulty paying attention; easily distracted; disorganized; losing items; often making careless mistakes; caffeine having little impact; impatient; difficulty waiting in lines; starting projects and not finishing; reading several books at the same time; difficulty remaining still; have been told by others that you don't listen well; difficult to not interrupt others; tendency to be very talkative; often "on the go"; act as if "driven by a motor"; feel as if thoughts are racing; periods where you feel "on top of the world" and can accomplish anything; unrestrained buying sprees, periods where car is driven at high speeds

feeling empty; feeling life has no meaning; a history of purposely cutting or physically hurting your body; suspecting that your partner is unfaithful; need a lot of reassurance from others; feel as if people will abandon you; always needing to be in a relationship; like to be the center of attention; perfectionistic