| Symptoms | 0 | 1 | 2 | 3 |
| 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) |
|
|
|
|
| Subtotal: |
|
|
|
|