Adult Symptom Checklist Adult Symptom Checklist Please mark any symptoms you are currently experiencing Name* First Last Email* Phone*Please mark any symptoms you are currently experiencing Abuse -physical, emotional, sexual, neglect (of yourself or someone else) Aggression/violence Anxiety, nervousness Attention, concentration, distractibility Career concerns, goals, life choices Co-Dependence Compulsions Depression, low mood, sadness, crying Divorce, separation Drug use (prescription, over-the-counter, street drugs) Eating problems (over-eating, under-eating, appetite, vomiting) Failure Fatigue, tiredness, low energy Fears, phobias Financial concerns, debt, impulsive spending, low income Gambling Grief, mourning, loss, death, divorce Headaches, stomachaches, or other physical pain Health concerns, illness, medical, physical concerns Inferiority, low self-esteem Impulsiveness, poor impulse control Judgment problems, risk taking Legal matters, legal charges, lawsuits Loneliness Marital issues, infidelity, remarriage Menstrual issues, PMS, menopause Mood swings Motivation issues, laziness Obsessions, compulsions (repetitive thoughts or actions) Over Sensitive to rejection Panic or anxiety attacks Parenting concerns, child management issues Perfectionism Procrastination, work inhibitions Pregnancy (infertility, miscarriage, termination/abortion) School problems Self-harm (cutting, burning, etc.) Sexual issues, desire differences, gender concerns, sexual dysfunction Shyness, oversensitivity to criticism Sleep problems (too much, too little, insomnia, nightmares) Smoking, vaping, tobacco use Spiritual, religious, moral, ethical issues Stress, tension, trouble relaxing Suicidal thoughts Weight concerns, dieting Withdrawal, isolating Work issues, employment, unemployment, workaholism, can’t keep a job, ambition Other (Please explain.PhoneThis field is for validation purposes and should be left unchanged.
