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 "]
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 1, 31 form elements, 43 boilerplate words, 14 check lists, 1 radio buttons, 16 drop downs, 157 total clicks
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