Symptom Checklist

Depression Symptoms
[checklist name="variable_1" value="Sad / Dysphoric Mood  |Irritability|Anhedonia|Social  w/drawal And Isolation|Difficulty  w/ Onset Of Sleep Up -1 Hour|Difficulty  w/ Onset Of Sleep1 - 2 Hours|Difficulty  w/ Onset Of Sleep Greater Than 2 Hours|Waking In  Middle Of  Night|Early Morning Awakening|Daytime Fatigue|Loss Of Appetite|Increased Appetite|Difficulty Concentrating|Decreased Attention|Worried, Ruminating Thoughts|Worthlessness|Excessive Guilt|Thoughts Of Death"][select name="variable_1" value="[radio name="variable_1" value="None|Mild|Moderate|Severe"]
[select name="variable_1" value="[radio name="variable_1" value="<2 Weeks|2 - 4 Weeks| 3 - 6 Months|>6 Mo"]
Elevated Mood Symptoms
[checklist name="variable_1" value="Hypomanic|Manic|Pressured Speech|Extreme Irritability|Extreme Agitation|Intrusiveness|Elevated / Elated Mood|Grandiosity|Decreased Need For Sleep|Flight Of Ideas|Distractibility|Psychomotor Agitation/Restlessness|Mood Lability|Hypertalkative|Hypersexual"][select name="variable_1" value="[radio name="variable_1" value="None|Mild|Moderate|Severe"]
[select name="variable_1" value="[radio name="variable_1" value="<2 Weeks|2 - 4 Weeks| 3 - 6 Months|>6 Mo"]
Suicidal Thoughts   
[select name="variable_1" value="None|Passive Suicidal Thoughts|Active Suicidal Thoughts |Suicidal Intent |Suicide Plan +++Access - Means"]
Previous Suicide Attempts  
[select name="variable_1" value=""variable_1" value="None |1|2|3|> 4"]
Most Recent Suicide Attempt
[select name="variable_1" value="None|<2 Weeks|2 - 4 Weeks|1 - 2 Months|3 - 6 Months|>6 Mo"]
Self Injurious Behaviors      
[checklist name="variable_1" value="Cutting|Burning|Piercing|Other"][radio name="variable_1" value="None|Mild|Moderate|Severe"]
Homicidal Thoughts   
[select name="variable_1" value="Passive Homicidal Thoughts  |Active Homicidal Thoughts|Homicidal Intent|Homicidal Plan|Access - Means"]
Anxiety Symptoms      
[checklist name="variable_1" value="Worries|Need For Reassurance |What If Questions |Social Phobia |Obsessions|Compulsions |Panic Attacks |Flashbacks|Avoidance Behaviors |Mutism |Freezing/Shutting Down"]
Somatic Complaints   
[checklist name="variable_1" value="Hypervigilance|Hyperarousal|Nightmares|Insomnia |Restlessness / “Feeling Keyed Up”|Muscle Tension |Mind Going Blank |Fatigue |Intrusive Memories |Palpitations |Sweating |Trembling / Shaking |Shortness Of Breath |Feeling Of Choking |Chest Discomfort/Tightness |Nausea / Abdominal Distress |Feeling Dizzy, Lightheaded, Unsteady / Faint|Feelings Of Unreality / Being Detached |Fear Of Losing Control / Going Crazy |Fear Of Dying |Numbness / Tingling Sensations|Chills / Hot Flashes|Subjective Sense Of Numbing, Detachment, / Absence Of Emotional Responsiveness |Derealization | Depersonalization | Reduction In Awareness Of Surrounding/In Daze"][select name="variable_1" value="[radio name="variable_1" value="None|Mild|Moderate|Severe"][select name="variable_1" value="[radio name="variable_1" value="<2 Weeks|2 - 4 Weeks| 3 - 6 Months|>6 Mo"]
Obsessive Symptoms  
[checklist name="variable_1" value="Contamination;Fear Of Germs, Dirt|Imagined Harm to Self or Others|Fear of Losing Control;Aggressive Urges|Intrusive Sexual Thoughts|Religious, Moral Preoccupation|Forbidden Thoughts| Need to Have Things In Place| Need to Tell, Ask,Confess|Other"]
[select name="variable_1" value="[radio name="variable_1" value="None|Mild|Moderate|Severe"][select name="variable_1" value="[radio name="variable_1" value="<2 Weeks|2 - 4 Weeks| 3 - 6 Months|>6 Mo"]
Compulsive Symptoms
[checklist name="variable_1" value="Washing | Repeating |Checking |Touching | Counting |Ordering / Arranging |Hoarding / Saving |Praying"][select name="variable_1" value="[radio name="variable_1" value="None|Mild|Moderate|Severe"][select name="variable_1" value="[radio name="variable_1" value="<2 Weeks|2 - 4 Weeks| 3 - 6 Months|>6 Mo"]
Anger Behaviors 
[checklist name="variable_1" value="  Often Loses Temper |Often Argues  w/ Others |Often Actively Defies / Refuses - Comply  w/ Requests / Rules |Deliberately Annoys People |Blames Others For Mistakes / Behaviors |Easily Annoyed | Angry And Resentful |Spiteful / Vindictive"][select name="variable_1" value="[radio name="variable_1" value="None|Mild|Moderate|Severe"][select name="variable_1" value="[radio name="variable_1" value="<2 Weeks|2 - 4 Weeks| 3 - 6 Months|>6 Mo"]

Depression:
[checklist name="Depression" value="Depressed Mood|Emotionally withdrawn/isolated|Anhedonia (loss of interest)|Appetite Disturbance|Sleep Disturbance|Decreased Energy|Feelings of Guilt or Worthlessness|Difficulty concentrating, thinking, or making decisions"]

Anxiety/PTSD:[checklist name="Anxiety/PTSD" value="Apprehensive expectation|hyper vigilance and scanning|Avoidance|Recurrent severe panic attacks|Recurrent obsessions and compulsions which are a source of distress| Nightmares/recurrent and intrusive memories of a traumatic experience|Difficulty leaving the house/agoraphobia"]

Mania:[checklist name="Mania" value="Involvement in activities with high probability of negative consequences (which aren't recognized)|Intense and unstable personal relationships|Impulsive and damaging behavior|Inflated Self-Esteem|Decreased need for sleep|elevated mood|rapid or pressured speech"]

Psychosis: [checklist name="Psychosis" value="AH, VH, TH (feel) OH (smell)|Disorganized thoughts/speech|Paranoia or inappropriate|suspiciousness
|Delusional cognitive content
|Catatonic or gross disorganized bx
|Incoherence, illogical thinking
|blunt affect
|flat affect
|pressured speech
|flight of ideas
|oddities of thought, perception, speech, or behavior"]


which has resulted in significant difficulties maintaining
[checklist name="difficulty" value="social fx|concentration|persistence "]

leading to[checklist name="leading to" value="repeated episodes of|decompensation|hospitalization|incarceration
"]