Adolescent Problematic Symptoms Checklist
Dr. Carol S. McCleary, Licensed Clinical psychologist
(To be filled out by the Adolescent)
Adolescent’s Name: _________________________Today’s Date: _____________________
Date of Birth: __________________________ Age:__________________
DIRECTIONS: (To be filled out by the adolescent.) This inventory is designed to get a
picture of the presenting symptoms you are experiencing. Read each item carefully and don’t
spend too much time on any one item. If you are displaying the symptoms at all, place a
check before that item.
Section I (ADD)
□ Failing to give close attention to details
or makes careless mistakes
□ Difficulty sustaining attention
□ Not appearing to listen
□ Struggling to follow through on
instructions
□ Difficulty with organization
□ Avoiding or disliking tasks requiring
sustained mental effort
□ Easily distracted
□
□
□
□
□
□
□
□
□
Forgetful in daily activities
Fidgeting with hands or feet or
squirming in chair
Difficulty remaining seated
Running around or climbs excessively
Difficulty engaging in activities quietly
Acting as if driven by a motor
Talking excessively
Difficulty waiting or taking turns
Interrupting or intruding upon others
Section II (D)
□ Persistent, sad, anxious or "empty" feelings
□ Feelings of hopelessness and/or pessimism
□ Feelings of guilt, worthlessness and/or helplessness
□ Irritability, restlessness
□ Loss of interest in activities or hobbies once pleasurable, including sex
□ Fatigue and decreased energy
□ Difficulty concentrating, remembering details and making decisions
□ Insomnia, early-morning wakefulness, or excessive sleeping
□ Overeating, or appetite loss
□ Thoughts hurting self
□ Persistent aches or pains, headaches, cramps or digestive problems that do not ease even
with treatment
Section III (GAD)
Page 1 of 5
□
□
□
□
□
□
□
□
□
Worry very much about everyday things,
even if there is little or no reason to
worry about them
Can't control the constant worries
Worry much more than should
Can't relax.
Have a hard time concentrating
Easily startled
Trouble falling asleep or staying asleep
Feeling tired for no reason
Headaches
Section IV (CD)
□ Negativity
□ Defiance
□ Disobedience
□ Hostility directed toward authority figures
□ Temper tantrums
□ Argumentativeness
□ Refusal to comply with adult requests
or rules
□ Deliberate annoyance of other people
□ Blaming others for mistakes or
misbehavior
□ Acting touchy and easily annoyed
□ Anger and resentment
□ Spiteful or vindictive behavior
□ Aggressiveness toward peers
□ Difficulty maintaining friendships
□ Academic problems
□
□
□
□
□
□
□
□
□
□
Muscle tension and aches
Having a hard time swallowing
Trembling or twitching
Being irritable
Sweating
Nausea
Feeling lightheaded
Feeling out of breath
Having to go to the bathroom a lot
Hot flashes
□
Aggressive behavior that harms or
threatens other people or animals
Destructive behavior that damages or
destroys property
Lying or theft
Truancy or other serious violations of
rules
Early tobacco, alcohol, and substance
use and abuse
Precocious sexual activity
Exhibits physical acts of cruelty to
people or animals
Frequently involved in fights, bullying or
intimidation
Will use a weapon in fights
Theft
Tends to run away from home
Ignores set curfew times
□
□
□
□
□
□
□
□
□
□
□
Section V (Ph)
□ Fear of places or situations where getting help or escape might be difficult., such as in a
crowd
□ Persistent and unreasonable fear of an object or situation, such as flying, heights, animals,
blood, etc.?
□ Being unable to travel alone?
□ Very anxious about being with other people
Page 2 of 5
□
□
□
□
□
□
□
Very self-conscious in front of other people
Very afraid of being embarrassed in front of other people
Very afraid that other people will judge you
Worry for days or weeks before an event where other people will be
Stay away from places where there are other people
Have a hard time making friends and keeping friends
May have body symptoms when they are with other people, such as:
o Blushing
o Heavy sweating
o Trembling
o Nausea
o Have a hard time talking
Section VI (OCD)
□ Have unwanted thoughts, ideas, images, or impulses that seem silly, nasty, or horrible
□ Worry excessively about dirt, germs, or chemicals
□ Constantly worry that something bad will happen because you may not have locked the
door or turned off appliances
□ Afraid you will act or speak aggressively when you really don't want to
□ Must do things excessively or must repeat thoughts to feel comfortable
□ Wash self or items excessively
□ Check things over and over again or repeat things many times to be sure they are done
properly
□ Avoid situations or people you worry about hurting through aggressive words or deeds
□ Keep many useless things because you feel you can't throw them away
Section VII (ED)
□ A relentless pursuit of thinness and unwillingness to maintain a normal or healthy weight
□ A distortion of body image and intense fear of gaining weight
□ A lack of menstruation among girls and women
□ Extremely disturbed eating behavior
□ Lost weight by dieting and exercising excessively
□ Lost weight by self-induced vomiting, or misusing laxatives, diuretics or enemas
□ See self as overweight
□ Recurrent and frequent episodes of eating unusually large amounts of food
□ Feeling a lack of control over the eating
□ Fasting
Page 3 of 5
□
□
Overweight or obese
Experience guilt, shame and/or distress about the binge-eating
Section VIII (Sz)
□ I see, hear, smell, or feel things that no one else can see, hear, or smell
□ Invisible fingers touch my body when no one is near
□ I can smell odors that no one else detects
□ I see people or objects that others cannot see
□ Neighbors can control my behavior with magnetic wave
□ Trouble organizing thoughts or connecting them logically
□ Agitated, repetitive or frozen in body movements
□ Lack of pleasure in everyday life
□ Lack of ability to begin and sustain planned activities
□ Trouble focusing or paying attention
Section IX (SA)
Please circle the answer that applies
A SHORT QUESTIONNAIRE ABOUT YOUR ALCOHOL USE
C - Have you ever thought you should CUT DOWN on your drinking? Y N
A - Have you ever felt ANNOYED by others' criticism of your drinking? Y N
G - Have you ever felt GUILTY about your drinking? Y N
E - Do you have a morning EYE OPENER? Y N
Section X (SA)
□ Increased tolerance for drug or alcohol
□ Continued use of drug or alcohol
despite physical problems
□ Abdominal pain
□ Nausea
□ Vomiting
□ Red eyes, puffy face numbness in the
arms or legs
□ Swelling of the liver
□ Blackouts, not remembering drinking
episodes
□ Solitary drinking
□ Unexplained mood swings
□ Missing work
□ Losing interest in social activities
□ Driving Under the Influence (DUI)
□
□
□
□
□
□
□
□
□
Page 4 of 5
Sudden personality changes that include
abrupt changes in quality of work, work
output, Unusual flare-ups or outbreaks
of temper
Withdrawal from responsibility
General changes in overall attitude
Loss of interest in what were once
favorite hobbies and pursuits
Changes in friends and reluctance to
have friends visit or talk about them
Difficulty in concentration, paying
attention
Sudden jitteriness, nervousness, or
aggression
Increased secretiveness
Deterioration of physical appearance and
grooming
□
Wearing of sunglasses at inappropriate
time
Please circle the answer that applies
1. Have you used drugs other than those required for medical reasons? Y N
2. Have you abused prescription drugs? Y N
3. Do you abuse more than one drug at a time? Y N
4. Can you get through the week without using drugs (other than those required for medical
reasons)? Y N
5. Are you always able to stop using drugs when you want to? Y N
6. Do you abuse drugs on a continuous basis? Y N
7. Do you try to limit your drug use to certain situations? Y N
8. Have you had “blackouts” or “flashbacks” as a result of drug use? Y N
9. Do you ever feel bad about your drug abuse? Y N
10. Does your spouse (or parents) ever complain about your involvement with
drugs? Y N
11. Do your friends or relatives know or suspect you abuse drugs? Y N
12. Has drug abuse ever created problems between you and your spouse? Y N
13. Has any family member ever sought help for problems related to your drug use? Y N
14. Have you ever lost friends because of your use of drugs? Y N
15. Have you ever neglected your family or missed work because of your use of
drugs? Y N
16. Have you ever been in trouble at work because of drug abuse? Y N
17. Have you ever lost a job because of drug abuse? Y N
18. Have you gotten into fights when under the influence of drugs? Y N
19. Have you ever been arrested because of unusual behavior while under the influence of
drugs? Y N
20. Have you ever been arrested for driving while under the influence of drugs? Y N
21. Have you engaged in illegal activities in order to obtain drug? Y N
22. Have you ever been arrested for possession of illegal drugs? Y N
23. Have you ever experienced withdrawal symptoms as a result of heavy drug
intake? Y N
24. Have you had medical problems as a result of your drug use (e.g., memory loss,
hepatitis, convulsions, bleeding, etc.)? Y N
25. Have you ever gone to anyone for help for a drug problem? Y N
26. Have you ever been in a hospital for medical problems related to your drug use? Y N
27. Have you ever been involved in a treatment program specifically related to drug
use? Y N
28. Have you been treated as an outpatient for problems related to drug abuse? Y N
Page 5 of 5