Fillable PATIENT LABEL BEHAVIORAL HEALTH ADULT SYMPTOM CHECKLIST DEPARTMENT (Sutter Health )

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PATIENT LABEL BEHAVIORAL HEALTH ADULT SYMPTOM CHECKLIST DEPARTMENT (Sutter Health )

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140701
(04/16)
DEPARTMENT OF PSYCHIATRY AND
BEHAVIORAL HEALTH
ADULT SYMPTOM CHECKLIST
PATIENT LABEL
Patient Name: Date:
Please check the appropriate degree of any symptoms you have experienced in the last month.
1=Never 2=Rarely 3=Occasionally 4=Frequently 5=Usually
Constant sadness/depressed mood 9 1 9 2 9 3 9 4 9 5
Difculty falling asleep 9 1 9 2 9 3 9 4 9 5
Fear of bridges/heights/
social situations 9 1 9 2 9 3 9 4 9 5
Early morning awakening 9 1 9 2 9 3 9 4 9 5
Feelings of anxiety 9 1 9 2 9 3 9 4 9 5
Waking during the middle of the night 9 1 9 2 9 3 9 4 9 5
Feeling on edge 9 1 9 2 9 3 9 4 9 5
Increased sleep 9 1 9 2 9 3 9 4 9 5
Panic attacks 9 1 9 2 9 3 9 4 9 5
Decreased enjoyment in formerly
Trembling/shakiness 9 1 9 2 9 3 9 4 9 5
pleasurable activities
9 1 9 2 9 3 9 4 9 5
Restlessness 9 1 9 2 9 3 9 4 9 5
Feelings of guilt 9 1 9 2 9 3 9 4 9 5
Irritability 9 1 9 2 9 3 9 4 9 5
Low self esteem 9 1 9 2 9 3 9 4 9 5
Shortness of breath 9 1 9 2 9 3 9 4 9 5
Feelings of helplessness 9 1 9 2 9 3 9 4 9 5
Heart palpitations/chest pain 9 1 9 2 9 3 9 4 9 5
Feelings of hopelessness 9 1 9 2 9 3 9 4 9 5
Sweats 9 1 9 2 9 3 9 4 9 5
Fatigued/low energy 9 1 9 2 9 3 9 4 9 5
Dizziness 9 1 9 2 9 3 9 4 9 5
Decreased concentration 9 1 9 2 9 3 9 4 9 5
Nausea/abdominal distress 9 1 9 2 9 3 9 4 9 5
Indecisiveness/slowed thinking 9 1 9 2 9 3 9 4 9 5
Headaches 9 1 9 2 9 3 9 4 9 5
Appetite 9 up/ 9 down 9 1 9 2 9 3 9 4 9 5
Feeling dissociated 9 1 9 2 9 3 9 4 9 5
Weight 9 up/ 9 down
How much?____lbs 9 1 9 2 9 3 9 4 9 5
Menstrual problems/changes 9 1 9 2 9 3 9 4 9 5
Crying spells 9 1 9 2 9 3 9 4 9 5
Urinary problems 9 1 9 2 9 3 9 4 9 5
Suicidal thoughts 9 1 9 2 9 3 9 4 9 5
Sexual problems 9 1 9 2 9 3 9 4 9 5
Attempts to hurt self/cutting on self 9 1 9 2 9 3 9 4 9 5
Unexplained pain 9 1 9 2 9 3 9 4 9 5
Diminished sex drive 9 1 9 2 9 3 9 4 9 5
Other physical symptoms 9 1 9 2 9 3 9 4 9 5
Tendency to isolate 9 1 9 2 9 3 9 4 9 5
Needing to be with others excessively 9 1 9 2 9 3 9 4 9 5
Decreased ability to sustain focus 9 1 9 2 9 3 9 4 9 5
Difculty with relationships
Difculty in organizing tasks 9 1 9 2 9 3 9 4 9 5
(spouse, children, co-workers)
9 1 9 2 9 3 9 4 9 5
Forgetfulness 9 1 9 2 9 3 9 4 9 5
Decreased effectiveness at work/home 9 1 9 2 9 3 9 4 9 5
Distractibility 9 1 9 2 9 3 9 4 9 5
Overeating/Binge eating 9 1 9 2 9 3 9 4 9 5
Feeling "hyper", restless
Anorexia 9 1 9 2 9 3 9 4 9 5
or wound up 9 1 9 2 9 3 9 4 9 5
Purging food (vomiting or laxatives) 9 1 9 2 9 3 9 4 9 5
Impulsive 9 1 9 2 9 3 9 4 9 5
Dramatic mood swings 9 1 9 2 9 3 9 4 9 5
Amnesia 9 1 9 2 9 3 9 4 9 5
Increased energy 9 1 9 2 9 3 9 4 9 5
Feelings of numbness 9 1 9 2 9 3 9 4 9 5
Feeling elated 9 1 9 2 9 3 9 4 9 5
Nightmares 9 1 9 2 9 3 9 4 9 5
Racing thoughts 9 1 9 2 9 3 9 4 9 5
Overspending 9 1 9 2 9 3 9 4 9 5
Bizarre/unusual experiences 9 1 9 2 9 3 9 4 9 5
Increased sexual activities 9 1 9 2 9 3 9 4 9 5
Hearing/seeing things others do not 9 1 9 2 9 3 9 4 9 5
Decreased need for sleep 9 1 9 2 9 3 9 4 9 5
Repetitive bothersome thoughts 9 1 9 2 9 3 9 4 9 5
Repetitive behaviors/compulsions 9 1 9 2 9 3 9 4 9 5
Alcohol use/abuse or dependency 9 1 9 2 9 3 9 4 9 5
Other drug use/abuse or dependency 9 1 9 2 9 3 9 4 9 5
Difculty with control of anger 9 1 9 2 9 3 9 4 9 5
Concerns about alcohol use 9 1 9 2 9 3 9 4 9 5
Homicidal thoughts/hurting others 9 1 9 2 9 3 9 4 9 5
Family/legal problems due to
Attempts to hurt others 9 1 9 2 9 3 9 4 9 5
alcohol/drugs 9 1 9 2 9 3 9 4 9 5
Have actually hurt others 9 1 9 2 9 3 9 4 9 5
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PATIENT LABEL BEHAVIORAL HEALTH ADULT SYMPTOM CHECKLIST DEPARTMENT (Sutter Health )

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Completed 2 May 2021

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