FEELINGS OF:

ñ Anxiety

ñ Depression

ñ Low Self Worth

ñ Jealousy

ñ Tension

ñ Anger/Rage

ñ Boredom

ñ Loss of Interest in pleasurable things

             (explain )____________________

 

ñ Excessive need for pleasure/thrills

             (explain)_____________________

ñ Hopelessness

ñ Thoughts racing

ñ Poor concentration/distracted

ñ Difficulty in making decisions

 

ABUSE:

ñ Sexual

ñ Physical

Explain: __________________________

_________________________________

_________________________________

_________________________________

 

OTHER

ñ Legal/Criminal troubles

             (explain)_____________________

 

EXPERIENCE OF:

ñ Vivid Dreams

             (explain) ________________________

ñ Nightmares

ñ        (explain) ________________________

ñ Hearing voices

ñ Memory problems

             (explain) _________________________

ñ Loss of orientation to time, place, or person

             (explain) _________________________

ñ Hallucinations

             (describe) ________________________

ñ Sexual problem

             (describe) ________________________

ñ Accelerated heart rate

ñ Increased sweating

ñ Chest pain

ñ Choking

ñ Difficulty breathing

ñ Hot flashes

 

SUBSTANCE USE:

ñ Type of substance(s) used (e.g. alcohol, marijuana) __________________________________

      Last date of use: ____________________

      Describe previous substance use: _______

      __________________________________

      __________________________________

      _________________________________

      Frequency of use ____________________

      Amount of use ______________________

Description of Symptoms Continued

 

Name and Date: _______________________________________________________________

Please review the boxes you checked and circle those of greatest concern to you right now.