PROBLEM CHECKLIST

Thank you for downloading Counseling for Contentment’s
Individual Problem Checklist
Directions: Read through the list of symptoms below. Then,
rate the ones you are experiencing on a scale from one to three
in the corresponding gray fields. (1 = mild, 2 = moderate,3 = severe)
When finished, please save the pdf file as your last name (ex Smith.pdf) and Email to: mariechoppin@counselingforcontentment.com, with the pdf as an attachment. We look forward to hearing from you and helping you on your path to contentment.

NAME :
DATE OF BIRTH:
DATE:

Emotional Concerns

ÿ       feeling anxious or uptight

ÿ       excessive worrying

ÿ       not being able to relax

ÿ       feeling panicky

ÿ       unable to calm yourself down

ÿ       dwelling on certain thoughts or images

ÿ       fearing something terrible is about to happen

ÿ       avoiding certain thoughts or feelings

ÿ       having strong fears

ÿ       worrying about a nervous breakdown

ÿ       feeling out of control

ÿ       fears of being alone or abandoned

ÿ       feeling guilty

ÿ       having nightmares

ÿ       flashbacks

ÿ       troubling or painful memories

ÿ       missing periods of time - can’t remember

ÿ       trouble remembering things

ÿ       feeling numb instead of upset

ÿ       feeling detached from all or part of your body

ÿ       having obsessive/ruminating thoughts

ÿ       feeling unreal, strange or foggy

Behavioral and Physical Concerns

ÿ       not having an appetite

ÿ       having obsessive behaviors such as:

ÿ       hand-washing, checking, counting, etc.

ÿ       eating in binges

ÿ       self induced vomiting for weight control

ÿ       using laxatives for weight control

ÿ       eating too much

ÿ       eating too little

Individual Problem Checklist

ÿ       feeling unmotivated

ÿ       loss of interest in many things

ÿ       having trouble concentrating

ÿ       having trouble making decisions

ÿ       feeling the future looks hopeless

ÿ       feeling worthless or like a failure

ÿ       being unhappy all the time

ÿ       dissatisfied with physical appearance

ÿ       feeling self critical or blaming yourself

ÿ       having negative thoughts

ÿ       crying often

ÿ       feeling empty

ÿ       withdrawing inside yourself

ÿ       thinking too much about death

ÿ       thoughts of hurting yourself

ÿ       thoughts of killing yourself

ÿ       frequent mood swings

ÿ       feeling resentful or angry

ÿ       feeling irritable or frustrated

ÿ       feeling rage

ÿ        feeling like hurting someone

ÿ       losing weight - how much?

ÿ       gaining weight - how much?

ÿ       avoiding being with people

ÿ       being tired and lacking energy

ÿ        excessive exercise

Behavioral and Physical Concerns Continued

ÿ       trouble finishing things

ÿ       cutting or harming self

ÿ       trouble sleeping

ÿ       trouble falling asleep

ÿ       early morning awakening

ÿ       sleeping too much

ÿ       sleeping too little

ÿ       number of hours I usually sleep:

ÿ       aggressive toward others

ÿ       impulsive reactions

ÿ       working too hard

ÿ       using alcohol too much

ÿ       being alcoholic

ÿ       using drugs

ÿ       driving under the influence

ÿ       blackouts - after drinking

ÿ       lack of exercise

Intimate Relationship Concerns

ÿ       feeling misunderstood in relationship

ÿ       not feeling close to partner

ÿ       trouble communicating with partner

ÿ       not trusting partner

ÿ       lack of respect by partner

ÿ       partner being secretive

ÿ       lack of fairness in relationship

ÿ       problems with dividing household tasks

ÿ       disagreeing about children

ÿ       lack of affection

ÿ       unsatisfactory sexual relationship

ÿ       lack of time together

ÿ       lack of shared interests

ÿ       lack of positive interaction

ÿ       lack of time with other couples

ÿ       jealousy in relationship frequent arguments

ÿ       not having leisure activities

ÿ       smoking cigarettes

ÿ       often spending in binges

ÿ       Have you ever felt you ought to cut down on your

ÿ       drinking or drug use? Yes No

ÿ       Have people annoyed you by criticizing your drinking

ÿ       or drug use? Yes No

ÿ       Have you ever felt bad or guilty about your drinking

ÿ       or drug use? Yes No

ÿ       Have you ever had a drink or used drugs first thing in

ÿ       the morning to steady your nerves or to get rid of a

ÿ       hangover? Yes No

ÿ       trouble resolving conflict

ÿ       partner being demanding and controlling

ÿ       partner putting you down

ÿ       violent arguments

ÿ       emotional abuse in relationship

ÿ       physical abuse in relationship

ÿ       sexual abuse in relationship

ÿ       partner having alcohol or drug problem

ÿ       self or partner having an affair

ÿ       feeling uncommitted to relationship

ÿ       wanting to separate

ÿ       discussing separating or divorce

ÿ       problems with in-laws

ÿ       problems with ex-partner

ÿ       problems with step parents

ÿ        children having special problems

Sexual Concerns

ÿ       worrying about getting pregnant

ÿ       having miscarriage(s)

ÿ       choice of birth control and/or abortion

ÿ       not able to become pregnant

ÿ       not enjoying sexual affection

ÿ       too tired to have sex

ÿ       too anxious to have sex

ÿ       feeling a lack of sexual desire

ÿ       wanting to have sex more often

ÿ        feeling neglected sexually

When Growing Up to Present Time

ÿ       being physically abused - by whom?

ÿ       being emotionally abused - by whom?

ÿ       being sexually abused - by whom?

ÿ       having an alcoholic parent - which?

ÿ       having a drug abusing parent - which?

ÿ       having a depressed parent - which?

ÿ       having a parent with emotional problems -

ÿ       which?

ÿ       having parents separate or divorce -

ÿ        your age at time of divorce?

Stresses During the Past Several Years

ÿ       death of family member or friend - who?

ÿ       birth or adoption of child

ÿ       self or family member hospitalized - who?

ÿ       moved/changed address

ÿ       being harassed or assaulted

ÿ       frequent family or couple arguments

ÿ        separation/divorce