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Symtom Checklist

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Submitted By kseniad
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Emilio Zamora

Symptoms: Please check the boxes for those symptoms that have increased recently in frequency (happen more often) or severity (gotten worse). If a symptom is extremely distressful, please put a star in the box.

very worried or anxious thought of ways to hurt/kill myself depressed mood restlessness (hard to sit still) drink/use drugs to feel better/relax tearfulness or crying excessive sweating feeling sad or blue dry mouth weight gain or loss guilty feelings dizziness or fainting spells eating more or less nightmares or bad dreams nausea or stomachaches more or less appetite hear voices/see things that headaches make myself vomit aren’t there fearful eat to feel better can’t have a good time heart palpitations (beats fast) physically abused feel numb feel cold or have chills sexually abused/molested want to be away from people feel hot or hot flashes verbally/emotionally abused isolated, separated, lonely muscles tension/tightness think about things too much not close to family or friends feeling keyed up or hyper repetitive behaviors feel unsupported difficulty concentrating financial problems really shy around people have cut or carved on myself work too much or too little can’t make or keep friends have hurt myself on purpose hard time making decisions people don’t care about me trouble falling asleep get confused easily angry or frustrated trouble staying asleep memory problems can’t control my temper sleep too much or too little lose track of time or place am physically aggressive wake up exhausted procrastination am verbally aggressive unable to relax feeling slowed down feel like “I’m going crazy” irritable or grouchy throw/break things when upset less energy than usual talk too much or too fast impulsivity (acting w/o thinking) less interest in sex get into trouble w/ the law feeling worthless loss of interest in activities less talkative feeling hopeless suicidal thoughts or feelings

If there are any other symptoms you’re experiencing that are not listed, please add them here. Also, explain any of the above that you’d like us to know more about.

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