PROBLEM CHECKLIST
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 is about to happen
avoiding certain thoughts or feelings
having strong fears
worrying about a nervous breakdown
feeling out of control
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 your body
having obsessive/ruminating thoughts
feeling unreal, strange or foggy
Behavioral and Physical Concerns
not having an appetite
having obsessive behaviors such as:
hand-washing, checking, counting, etc.
eating in binges
self induced vomiting for weight control
using laxatives for weight control
eating too much
eating too little
Individual Problem Checklist
feeling unmotivated
loss of interest in many things
having trouble concentrating
having trouble making decisions
feeling the future looks hopeless
feeling worthless or like 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
losing weight - how much?
gaining weight - how much?
avoiding being with people
being tired and lacking energy
excessive exercise
Behavioral and Physical Concerns Continued
trouble finishing things
cutting or harming self
trouble sleeping
trouble falling asleep
early morning awakening
sleeping too much
sleeping too little
number of hours I usually sleep:
aggressive toward others
impulsive reactions
working too hard
using alcohol too much
being alcoholic
using drugs
driving under the influence
blackouts - after drinking
lack of exercise
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
not having leisure activities
smoking cigarettes
often spending in binges
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? Yes No
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 and/or 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
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 -
which?
having parents separate or divorce -
your age at time of divorce?
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/changed address
being harassed or assaulted
frequent family or couple arguments
separation/divorce
