Please rate yourself, or the person you are assessing on each of the symptoms below. Check one item on the rating scale for each symptom.
0 = not at all; 1 = mild; 2 = moderate; 3 = severe
Anxiety, uneasiness, worry, concern
Inattention, daydreaming, hard to stay on task
Depressed (guilt, helpless, hopeless, sad, blue)
Dull, slow to learn, not sharp
Forgetful, failure to recall or remember
Spaciness, fogginess, not turned in
Disrupted sleep, wakes often, difficulty waking
Cries easily, sheds tears, weep easily
Feelings easily hurt, vulnerable
Low self-esteem, poor self-confidence
Lack of motivation, discouraged
Confused thinking, mixed up, baffled
Nausea, sickness, upset stomach
Loss of emotional control, rage, wrath
Lethargic, lazy, drowsy, drowsy, sluggish, fatigue
Racing thoughts, many thoughts
Agitation, upset, disturbed
Hyperactive, excessive movement
Difficulty falling asleep
Impulsive, spontaneous urge
Physical tension in body, taut, nervous
Pressure or discomfort in chest
Aggressive, hostile, overly assertive & bold
Teeth grinding (bruxism), jaw clenching
Headaches or discomfort in head
Crawling sensation on skin; leg twitches
Sensitivity to touch (hands, feet, or face)
Pain awareness, unpleasant sensation
Hyper focused; overly attentive
Depressed (agitated or angry)
Have you changed your medication or dosage?
Have you changed your consumption of herbs or supplements?
Have you had any changes at home?
Are there any changes or observations you have noticed since your last visit?