Adult Assessment Form Are you the patient?(Required) Yes No, I am signing up on behalf of the patient Date(Required) MM slash DD slash YYYY Email Patient Name(Required) First Last Please check the appropriate degree of any symptoms you have experienced in the last month. 1 = Never | 2 = Rarely | 3 = Occasionally | 4 = Frequently | 5 =Usually Constant sadness/depressed mood(Required) 1 2 3 4 Fear of bridges/heights/social situations(Required) 1 2 3 4 Difficulty falling asleep(Required) 1 2 3 4 Feelings of anxiety(Required) 1 2 3 4 Waking during the middle of the night(Required) 1 2 3 4 Feeling on edge(Required) 1 2 3 4 Increased sleep(Required) 1 2 3 4 Panic attacks(Required) 1 2 3 4 Decreased enjoyment in formerly pleasurable activities(Required) 1 2 3 4 Trembling/shakiness(Required) 1 2 3 4 Feelings of guilt(Required) 1 2 3 4 Restlessness(Required) 1 2 3 4 Irritability(Required) 1 2 3 4 Low self esteem(Required) 1 2 3 4 Feelings of helplessness(Required) 1 2 3 4 Shortness of breath(Required) 1 2 3 4 Feelings of hopelessness(Required) 1 2 3 4 Shortness of breath(Required) 1 2 3 4 Fatigued/low energy(Required) 1 2 3 4 Heart palpitations/chest pain(Required) 1 2 3 4 Decreased concentration(Required) 1 2 3 4 Sweats(Required) 1 2 3 4 Indecisiveness/slowed thinking(Required) 1 2 3 4 Dizziness(Required) 1 2 3 4 Nausea/abdominal distress(Required) 1 2 3 4 Headaches(Required) 1 2 3 4 Feeling dissociated(Required) 1 2 3 4 Menstrual problems/changes(Required) 1 2 3 4 Appetite(Required) up down Appetite (cont.)(Required) 1 2 3 4 Weight(Required) up down Weight (cont.)(Required) 1 2 3 4 How much? (lbs)(Required)Crying spells(Required) 1 2 3 4 Urinary problems(Required) 1 2 3 4 Suicidal thoughts(Required) 1 2 3 4 Sexual problems(Required) 1 2 3 4 Unexplained pain(Required) 1 2 3 4 Attempts to hurt self/cutting on self(Required) 1 2 3 4 Diminished sex drive(Required) 1 2 3 4 Other physical symptoms(Required) 1 2 3 4 Tendency to isolate(Required) 1 2 3 4 Decreased ability to sustain focus(Required) 1 2 3 4 Needing to be with others excessively(Required) 1 2 3 4 Difficulty in organizing tasks(Required) 1 2 3 4 Difficulty with relationships (spouse, children, co-workers)(Required) 1 2 3 4 Forgetfulness(Required) 1 2 3 4 Decreased effectiveness at work/home(Required) 1 2 3 4 Distractibility(Required) 1 2 3 4 Overeating/Binge eating(Required) 1 2 3 4 Feeling "hyper", restless or wound up(Required) 1 2 3 4 Anorexia(Required) 1 2 3 4 Impulsive(Required) 1 2 3 4 Purging food (vomiting or laxatives)(Required) 1 2 3 4 Amnesia(Required) 1 2 3 4 Dramatic mood swings(Required) 1 2 3 4 Feelings of numbness(Required) 1 2 3 4 Increased energy(Required) 1 2 3 4 Nightmares(Required) 1 2 3 4 Feeling elated(Required) 1 2 3 4 Bizarre/unusual experiences(Required) 1 2 3 4 Racing thoughts(Required) 1 2 3 4 Hearing/seeing things others do not(Required) 1 2 3 4 Overspending(Required) 1 2 3 4 Repetitive bothersome thoughts(Required) 1 2 3 4 Increased sexual activities(Required) 1 2 3 4 Repetitive behaviors/compulsions(Required) 1 2 3 4 Decreased need for sleep(Required) 1 2 3 4 Difficulty with control of anger(Required) 1 2 3 4 Alcohol use/abuse or dependency(Required) 1 2 3 4 Homicidal thoughts/hurting others(Required) 1 2 3 4 Other drug use/abuse or dependency(Required) 1 2 3 4 Attempts to hurt others(Required) 1 2 3 4 Concerns about alcohol us(Required) 1 2 3 4 Have actually hurt others(Required) 1 2 3 4 Family/legal problems due to alcohol/drugs(Required) 1 2 3 4 Better days are ahead! Let's work together to create change. Start Now
