Psychological Symptoms Checklist

Printer Friendly Version

Circle the number, from 0 (never) to 4 (frequently), that represents the degree to which the following thoughts, feelings, and behaviors have bothered you during the past month.

0	=	Never
1	=	Rarely
2	=	Sometimes
3	=	Often
4	=	Frequently

THOUGHTS

1.	Awfulizing (fantasizing the worst possible outcome)	0	1	2	3	4
2.	Blaming myself	0	1	2	3	4
3.	Blaming others	0	1	2	3	4
4.	Difficulty concentrating	0	1	2	3	4
5.	Holding grudges	0	1	2	3	4
6.	Thinking and rethinking the same situation	0	1	2	3	4
7.	Wishing I could “turn my mind off”	0	1	2	3	4
8.	Constantly criticizing other people or situations	0	1	2	3	4
9.	Worrying	0	1	2	3	4
10.	Thinking something is wrong with my mind	0	1	2	3	4
11.	Needing to be right	0	1	2	3	4
12.	Feeling out of control	0	1	2	3	4

EMOTIONS

1.	Afraid of specific places or circumstances	0	1	2	3	4
2.	Feeling like a victim	0	1	2	3	4
3.	Anxious	0	1	2	3	4
4.	Blue	0	1	2	3	4
5.	Lonely	0	1	2	3	4
6.	Irritable	0	1	2	3	4
7.	Wanting to throw things or hit people	0	1	2	3	4
8.	Guilty	0	1	2	3	4
9.	Feeling unfriendly	0	1	2	3	4
10.	Uptight	0	1	2	3	4
11.	Hopeless about the future	0	1	2	3	4
12.	Wanting to “pull the covers over my head”	0	1	2	3	4
13.	Feeling that other people don’t like me	0	1	2	3	4
14.	Upset over criticism	0	1	2	3	4

BEHAVIORS

1.	Nail or cuticle biting	0	1	2	3	4
2.	Using tobacco in any form	0	1	2	3	4
3.	Taking tranquilizers or “street” drugs to change mood	0	1	2	3	4
4.	Drinking alcoholic beverages	0	1	2	3	4
5.	Chewing gum or sucking candies	0	1	2	3	4
6.	Talking a lot	0	1	2	3	4
7.	Crying a lot	0	1	2	3	4
8.	Sleeping problems (too much or too little)	0	1	2	3	4
9.	Eating problems (too much or too little)	0	1	2	3	4
10.	Trouble communicating	0	1	2	3	4
11.	Avoiding responsibilities	0	1	2	3	4
12.	Too much caffeine	0	1	2	3	4

Copyright © Jane Leserman, Ph.D., and Claudia Dorrington, 1986.

<< back