Screener - Adult Symptom Screener

Adult Symptom Screener
Today's Date*

MonthDayYear
Name*
Date Of Birth*

MonthDayYear
Therapist*

Susan Baker, M.Ed., LPCCarolina Roman, M.A., LMFTCathy Hein, MSSW, LCSWOlivia Pudlo, MSW, LCSWNatalie Andrepont, M.A., LPCLisa Kampwerth, MSW, LCSWLiana Merrill, BAMichele Wright, M.A., LPCNichole Campbell, MS, LPC-AAasiya Jiwani, BASarah McDuffee, M.A., LPC-A

Over the last two weeks how often have you been bothered by the following problems?*

	Not at all	Several days	More than half the days	Nearly every day
Feeling down, depressed or hopeless
Little interest in doing things?
Feeling nervous, anxious, or on edge
Not being able to stop or control worying

The following questions relate to your experiences over the last six months*

	Yes	No
In the past 6 months, did you ever have a spell or an attack when all of a sudden you felt frightened, anxious or very uneasy?
In the past 6 months, did you ever have a spell or attack when for no reason your heart suddenly began to race, you felt faint, or you couldn’t catch your breath?
Did any of these spells or attacks ever happen in a situation when you were not in danger or not the center of attention?

Please respond to the degree that the following problems have bothered you during the past week*

	Not at all	A little bit	Somewhat	Very much	Extremely
Fear of embarrassment causes me to avoid doing things or speaking to people
I avoid activities in which I am the center of attention
Being embarrassed or looking stupid are among

Please answer each question to the best of your ability*

	Yes	No
Have you experienced any of the following traumatic events: natural disaster (e.g., flood, hurricane, tornado, earthquake), fire, explosion, or industrial accident;; transportation accident (e.g., car accident, plane crash);; physical assault (e.g., being attacked, beaten up);; sexual assault (e.g., rape, attempted rape, made to perform any type of sexual act through force or threat of harm);; captivity or exposure to a war-zone;; life-threatening illness or injury;; sudden, unexpected death of or injury to someone close to you;; or serious injury, harm, or death to someone else that you witnessed or caused?
Has this event caused any significant problems or symptoms that lasted for more than a month?

Has there every been a period of time when you were not you usual self and*

	Yes	No
...you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
...you were so irritable that you shouted at people or started fights or arguments?
...you felt much more self-confident than usual?
...you got much less sleep than usual and found you didn’t really miss it?
...you were much more talkative or spoke much faster than usual?
...thoughts raced through your head or you couldn’t slow your mind down?
...you were so easily distracted by things around you that you had trouble concentrating or staying on track?
...you had much more energy than usual?
...you were much more active or did many more things than usual?
...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
...you were much more interested in sex than usual?
...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
...you were spending money that got you or your family into trouble?

The following questions relate to your eating habits:*

	Yes	No
When you eat, do you make yourself sick because you feel uncomfortably full?
Do you ever worry that you have lost control over how much you eat?
Have you recently lost more than 14 pounds in a 3 month period?
Do you believe yourself to be fat when others say you are too thin?
Would you say that food dominates your life?
Have you ever been bothered by having to perform some ritual or act over and over that does not make sense?

The following questions relate to your alcohol and substance use:

How often do you have a drink of alcohol?*

	Never	Monthly or less	2-4 times/month	2-3 times/week	4 or more times/week
Answer

How many drinks containing alcohol do you have a typical day when you are drinking?*

	0	1 - 2	3 - 4	5 - 6	7 - 9	10 or more
Answer

How often do you have six or more drinks on one occaision?*

	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
Answer

In the past year have you used an illegal drug or used a prescription medication for non-medical reasons?*

Yes No

Answer

	Yes	No
Answer

Please answer the questions below, rating yourself on each of the criteria shown using the scale provided. As you answer each question, select the option that best describes how you have felt and conducted your self over the past 6 months.*

	Never	Rarely	Sometimes	Often	Very Often
How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
How often do you have difficulty getting things in order when you have to do a task that requires organization?
How often do you have problems remembering appointments or obligations?
When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
How often do you feel overly active and compelled to do things, like you were driven by a motor?

The questions listed below relate to your thoughts and feelings. If the way you have been in recent weeks or months differs from the way you usually are, please answer based on when you were your usual self.*

	Yes	No
Do you find that most people will take advantage of you if you let them know too much about you?
Do you generally feel nervous or anxious around people?
Do you avoid situations where you have to meet new people?
Do you avoid getting to know people because you're worried that they may not like you?
Has avoidance of getting to know people due to fear of being disliked affected the number of friends that you have?
Do you keep changing the way you present yourself to people because you don't know who you really are?
Do you often feel like your beliefs change so much that you don't know what you really believe any more?
Do you often get angry or irritated because people don't recognize your special talents or achievements as much as they should?
Have you had any unusual experiences such as hearing voices, seeing visions, or having ideas you later found out were not true?
Have you had any other experiences, such as mind reading, ESP, thoughts being controlled by others, seeing things on TV that refer to you specifically?

Should be Empty: