|
|
|
|
I AM EXPERIENCING…
|
NEVER
|
SELDOM
|
OFTEN
|
ALWAYS
|
FOR HOW LONG?
|
Frequent worry or tension
|
never
|
seldom
|
often
|
always
|
|
Fear of many things
|
never
|
seldom
|
often
|
always
|
|
Discomfort in social situations
|
never
|
seldom
|
often
|
always
|
|
Feelings of guilt
|
never
|
seldom
|
often
|
always
|
|
Phobias: unusual fears of specific things
|
never
|
seldom
|
often
|
always
|
|
Panic Attacks: Shortness of breath, sweating, trembling, heart palpitations
|
never
|
seldom
|
often
|
always
|
|
Recurring, distressing thoughts about trauma
|
never
|
seldom
|
often
|
always
|
|
“Flashbacks” as if reliving trauma
|
never
|
seldom
|
often
|
always
|
|
Avoiding people/places associated with trauma
|
never
|
seldom
|
often
|
always
|
|
Nightmares about traumatic event
|
never
|
seldom
|
often
|
always
|
|
I AM FEELING…
|
NEVER
|
SELDOM
|
OFTEN
|
ALWAYS
|
FOR HOW LONG?
|
Decreased interest in pleasurable activities
|
never
|
seldom
|
often
|
always
|
|
Social Isolation/ Withdrawal
|
never
|
seldom
|
often
|
always
|
|
Suicidal Thoughts
|
never
|
seldom
|
often
|
always
|
|
Feelings of loss
|
never
|
seldom
|
often
|
always
|
|
Changes in sleep (too much, too little)
|
never
|
seldom
|
often
|
always
|
|
Normal, daily tasks require extra energy
|
never
|
seldom
|
often
|
always
|
|
Sad, hopeless about future
|
never
|
seldom
|
often
|
always
|
|
Excessive feelings about guilt
|
never
|
seldom
|
often
|
always
|
|
Low self-esteem
|
never
|
seldom
|
often
|
always
|
|
I NOTICE/OTHERS HAVE NOTICED…
|
NEVER
|
SELDOM
|
OFTEN
|
ALWAYS
|
FOR HOW LONG?
|
I am angry, hostile or irritable
|
never
|
seldom
|
often
|
always
|
|
I feel euphoric, energized, highly optimistic
|
never
|
seldom
|
often
|
always
|
|
I have racing thoughts
|
never
|
seldom
|
often
|
always
|
|
I require less sleep than normal
|
never
|
seldom
|
often
|
always
|
|
I am more talkative
|
never
|
seldom
|
often
|
always
|
|
My moods go up and down
|
never
|
seldom
|
often
|
always
|
|
I HAVE…
|
NEVER
|
SELDOM
|
OFTEN
|
ALWAYS
|
FOR HOW LONG?
|
Memory problems or trouble concentrating
|
never
|
seldom
|
often
|
always
|
|
Trouble explaining myself to others
|
never
|
seldom
|
often
|
always
|
|
Problems understanding what others tell me
|
never
|
seldom
|
often
|
always
|
|
Intrusive or strange thoughts
|
never
|
seldom
|
often
|
always
|
|
Obsessive thoughts
|
never
|
seldom
|
often
|
always
|
|
Hear voices or sounds when I’m alone
|
never
|
seldom
|
often
|
always
|
|
I ENGAGE IN…
|
NEVER
|
SELDOM
|
OFTEN
|
ALWAYS
|
FOR HOW LONG?
|
Risk taking behaviors
|
never
|
seldom
|
often
|
always
|
|
Compulsive or repetitive behaviors
|
never
|
seldom
|
often
|
always
|
|
Engage in activities without concern of consequences
|
never
|
seldom
|
often
|
always
|
|
Been physically harming myself
|
never
|
seldom
|
often
|
always
|
|
Been violent towards others
|
never
|
seldom
|
often
|
always
|
|
I USE THE FOLLOWING…
|
NEVER
|
SELDOM
|
OFTEN
|
ALWAYS
|
FOR HOW LONG?
|
Alcohol
|
never
|
seldom
|
often
|
always
|
|
Tobacco or Nicotine
|
never
|
seldom
|
often
|
always
|
|
Marijuana
|
never
|
seldom
|
often
|
always
|
|
Cocaine
|
never
|
seldom
|
often
|
always
|
|
Opiate Medication
|
never
|
seldom
|
often
|
always
|
|
Sedatives
|
never
|
seldom
|
often
|
always
|
|
Hallucinogens
|
never
|
seldom
|
often
|
always
|
|
Stimulants
|
never
|
seldom
|
often
|
always
|
|
Methamphetamine
|
never
|
seldom
|
often
|
always
|
|
Heroin
|
never
|
seldom
|
often
|
always
|
|
MY EATING INVOLVES…
|
NEVER
|
SELDOM
|
OFTEN
|
ALWAYS
|
FOR HOW LONG?
|
Restriction of food consumption
|
never
|
seldom
|
often
|
always
|
|
Binging and purging
|
never
|
seldom
|
often
|
always
|
|
Binge eating
|
never
|
seldom
|
often
|
always
|
|
Excessive weight gain or loss
|
never
|
seldom
|
often
|
always
|
|