Adult Checklist of Concerns  

Name: ________________________________________________________ Date: _____________________ 

Please mark all of the items below that apply, and feel free to add any others at the bottom under “Any other concerns or issues.” You may add a note or details in the space next to the concerns checked. (For a child, mark any of these and then complete the “Child Checklist of Characteristics.”)  

• I have no problem or concern bringing me here  

• Abuse—physical, sexual, emotional, neglect (of children or elderly), cruelty to animals  • Aggression, violence  

• Alcohol use  

• Anger, hostility, arguing, irritability  

• Anxiety, nervousness  

• Attention, concentration, distractibility  

• Career concerns, goals, and choices  

• Childhood issues (your own childhood)  

• Children, child management, child care, parenting  

• Codependence  

• Confusion  

• Compulsions  

• Custody of children  

• Decision making, indecision, mixed feelings, putting off decisions 

• Delusions (false ideas)  

• Dependence  

• Depression, low mood, sadness, crying  

• Divorce, separation  

• Drug use—prescription medications, over-the-counter medications, street drugs  • Eating problems—overeating, undereating, appetite, vomiting (see also “Weight and diet issues”)  

• Emptiness  

• Failure  

• Fatigue, tiredness, low energy  

• Fears, phobias  

• Financial or money troubles, debt, impulsive spending, low income  

• Friendships  

• Gambling 

• Gender / Gender Identity Concerns 

• Grieving, mourning, deaths, losses, divorce  

• Guilt   

• Headaches, other kinds of pains  

• Health, illness, medical concerns, physical problems  

• Inferiority feelings  

• Interpersonal conflicts  

• Impulsiveness, loss of control, outbursts  

• Irresponsibility  

• Judgment problems, risk taking  

• Legal matters, charges, suits  

• Loneliness  

• Marital conflict, distance/coldness, infidelity/affairs, remarriage  

• Memory problems  

• Menstrual problems, PMS, menopause  

• Mood swings  

• Motivation, laziness  

• Nervousness, tension  

• Obsessions, compulsions (thoughts or actions that repeat themselves)  • Oversensitivity to rejection  

• Panic or anxiety attacks  

• Perfectionism  

• Pessimism  

• Procrastination, work inhibitions, laziness  

• Relationship problems  

• School problems (see also “Career concerns . . .”)  

• Self-centeredness  

• Self-esteem  

• Self-neglect, poor self-care  

• Sexual issues, dysfunctions, conflicts, desire differences, other (see also “Abuse”)  • Shyness, oversensitivity to criticism  

• Sleep problems—too much, too little, insomnia, nightmares  

• Smoking and tobacco use  

• Stress, relaxation, stress management, stress disorders, tension  

• Suspiciousness  

• Suicidal thoughts  

• Temper problems, self-control, low frustration tolerance  

• Thought disorganization and confusion  

• Threats, violence  

• Weight and diet issues  

• Withdrawal, isolating  

• Work problems, employment, workaholism/overworking, can’t keep a job.

Any other concerns or issues:  

______________________________________________________________________ • 

______________________________________________________________________ Please look back over the concerns you have checked off and choose the one that you most want help with. It is:  

_________________________________________________________________________ This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.