individual problem checklist

                     Name: _____________________________________ Date:_________________ 
Individual Problem Checklist 
Directions:
     Put a number next to any item which you experience.      1=mildly,  2=moderately,  3=severely
Emotional Concerns
____feeling anxious or uptight 
____excessive worrying 
____not being able to relax 
____feeling panicky 
____unable to calm yourself down 
____dwelling on certain thoughts or images 
____fearing something terrible about to happen 
____avoiding certain thoughts or feelings 
____having strong fears 
____worrying about a nervous breakdown 
____feeling out of control 
____avoiding being with people 
____fears of being alone or abandoned 
____feeling guilty 
____having nightmares 
____flashbacks 
____troubling or painful memories 
____missing periods of time - can't remember 
____trouble remembering things 
____feeling numb instead of upset 
____feeling detached from all or part of body 
____feeling unreal, strange or foggy 
____feeling depressed or sad 
____being tired or lacking energy 
____feeling unmotivated 
____loss of interest in many things 
____having trouble concentrating 
____having trouble making decisions 
____feeling the future looks hopeless 
____feeling worthless or a failure 
____being unhappy all the time 
____dissatisfied with physical appearance 
____feeling self critical or blaming yourself 
____having negative thoughts 
____crying often 
____feeling empty 
____withdrawing inside yourself 
____thinking too much about death 
____thoughts of hurting yourself 
____thoughts of killing yourself 
____frequent mood swings 
____feeling resentful or angry 
____feeling irritable or frustrated 
____feeling rage 
____feeling like hurting someone
 __________________________________________________
Behavioral and Physical Concerns
____not having an appetite 
____eating in binges 
____self induced vomiting for weight control 
____using laxatives for weight control 
____eating too much 
____eating too little 
____losing weight - how much?_____ 
____gaining weight - how much?____ 
____trouble sleeping 
____trouble falling asleep 
____early morning awakening 
____sleeping too much 
____sleeping too little 
____# of hours I usually sleep: _____ 
____lack of exercise 
____not having leisure activities 
____smoking cigarettes 
____often spending in binges 
____temper outbursts 
____aggressive toward others 
____impulsive reactions 
____trouble finishing things 
____working too hard  
____using alcohol too much 
____being alcoholic 
____using drugs 
____driving under the influence 
____blackouts - after drinking 
___Yes ___No  Have you ever felt you ought to cut                 
down on your drinking or drug use? 
___Yes ___No  Have people annoyed you by 
criticizing your drinking or drug use? 
___Yes ___No Have you ever felt bad or guilty 
about your drinking or drug use? 
___Yes ___No Have you ever had a drink or used                     
drugs first thing in the morning to                   
steady your nerves or to get rid of a hangover? 
_______________________________________________
Intimate Relationship Concerns
____feeling misunderstood in relationship 
____not feeling close to partner 
____trouble communicating with partner 
____not trusting partner 
____lack of respect by partner 
____partner being secretive 
____lack of fairness in relationship 
____problems with dividing household tasks 
____disagreeing about children 
____lack of affection 
____unsatisfactory sexual relationship 
____lack of time together 
____lack of shared interests 
____lack of positive interaction ____lack of time with other couples 
____jealousy in relationship 
____frequent arguments 
____trouble resolving conflict 
____partner being demanding and controlling 
____partner putting you down 
____violent arguments 
____emotional abuse in relationship 
____physical abuse in relationship 
____sexual abuse in relationship 
____partner having alcohol or drug problem 
____self or partner having an affair 
____feeling uncommitted to relationship 
____wanting to separate 
____discussing separating or divorce 
____problems with in-laws 
____problems with ex-partner 
____problems with step parents 
____children having special problems 
 _________________________________________________
Sexual Concerns
____worrying about getting pregnant 
____having miscarriage(s) 
____choice of birth control 
____having an abortion 
____not able to become pregnant 
____not enjoying sexual affection 
____too tired to have sex 
____too anxious to have sex 
____feeling a lack of sexual desire 
____wanting to have sex more often 
____feeling neglected sexually 
____feeling used sexually 
____feeling unable to have orgasm 
____being unable to sustain an erection 
____feeling negatively about sex 
 _________________________________________________
When Growing Up to Present Time:
____being physically abused - by whom? 
____being emotionally abused - by whom? 
____being sexually abused - by whom? 
____having an alcoholic parent - which? 
____having a drug abusing parent - which? 
____having a depressed parent - which? 
____having a parent with emotional problems 
____having parents separate or divorce 
____close family member dying - who? 
____felt neglected or unloved - by whom 
____having an unhappy childhood 
____having serious medical problems - what? 
____having drug or alcohol problem 
____frequent moves 
____having learning problems - what? 
____having emotional problems 
____having attempted suicide - when? 
 ___________________________________________________
Stresses During the Past Several Years:
____death of family member or friend - who? 
____birth or adoption of child 
____self or family member hospitalized - who? 
____moved 
____being harassed or assaulted 
____frequent family or couple arguments 
____separation/divorce 
____an important relationship ending - who? 
____losing or changing job 
____financial trouble 
____legal problems 
____natural disaster 
____serious or chronic illness -what:________ 
 ____________________________________________
____other 
Please State Your Goals for Therapy: 
1.______________________________________________________________________________________________ 
2.______________________________________________________________________________________________ 
3.______________________________________________________________________________________________ 
  
Additional Comments: