Author: pamela

Symptom Checklist

Printed Name(s):___________________________________________________________
Date: ____________________________________________________________________
__________________________________________________________________________________________________________
Symptoms Checklist
It can be difficult to determine when to go to therapy. The Symptoms Checklist is intended as a guideline for you to clarify what you are currently experiencing and may wish to work on.
Please check the boxes that indicate any of the areas that are currently problems for you.
Place TWO check marks to indicate the most important reason(s).
____Feeling nervous or anxious ____Use/abuse of alcohol and/or drugs
____Feelings of Panic ____Difficulty with school or work
____Under pressure and feeling stressed ____Concerns about finances
____Needing to learn to relax ____Having difficulty being honest/open
____Afraid of being on your own ____Having difficulty communicating
____Feeling angry much of the time ____Having a hard time making friends
____Concerns about your violence ____Having a hard time keeping friends
____Difficulty expressing emotions ____Wishing you were more social
____Feeling inferior to others ____Feeling pressured by others
____Lacking in self-confidence ____Feeling controlled/manipulated
____Feeling down or unhappy ____Marital or couple problems
____Feeling lonely and/or isolated ____Family difficulties
____Guilty feelings ____Difficulties with children
____Feeling down on yourself ____Break-up of a relationship
____Thoughts of taking your own life ____Difficulties in sexual relationships
____Recent trauma or loss in your life ____Feeling guilty about sexual activities
____Concerns about emotional stability ____Feelings related to molestation or rape
____Feeling cut off from your emotions ____Concerns about childhood abuse
____Wondering “Who I am” ____Concerns about your weight
____Difficulty making decisions ____Difficulties with weight control
____Feeling confused much of the time ____Concerns about your physical health
____Difficulty controlling your thoughts ____Concerns about your appearance
____Difficulty controlling your actions ____Performing ritualistic behaviors
____Being suspicious of others ____Fear of losing control
Couple Relationship Difficulties
____Tension ____Communication problems ____Other (describe)
____Arguments ____Alcohol or drug problems _____________________________
____Emotional distance ____Stress from health problems _____________________________
____Sexual difficulties ____Stress from money problems ______________________________
Difficulties with Family and/or Children
____Tension with children ____Alcohol or drug problems ____Other (describe)
____Angry interchanges ____Financial problems _________________________________
with______________ ________________________________
______________________________
____Behavioral problems with children