A & D Symptoms Checklist

Name: Course & Year: Sex: Age: Date:

Instructions: Listed below are symptoms or concerns that people sometimes have. Please read each one carefully
and decide how much the symptoms bothered or distressed you in the last week, including today. Please put an x
mark in the appropriate column.

Part I: “A” Symptoms

SYMPTOMS Not at all A little Quite a bit Extremely
1 2 3 4
1. Suddenly scared for no reason
2. Feeling fearful
3. Faintness, dizziness, weakness
4. Nervousness/shakiness
5. Heart pounding/racing
6. Trembling
7. Feeling tensed or keyed up
8. Headaches
9. Spells/terror/panic
10. Feeling restless, can’t still
TOTAL

Part II: “D” Symptoms

SYMPTOMS Not at all A little Quite a bit Extremely

1 2 3 4
1. Feeling low in energy; slowed down
2. Blaming yourself for things
3.Crying easily
4.Loss of sexual interest of pleasure
5. Poor appetite
6. Difficulty falling asleep: staying asleep
7. Feeling hopeless about the future
8. Feeling blue
9. Feeling lonely
10. Thoughts of ending your life
11. Feeling being trapped or caught
12. Worrying too much about things
13. Feeling no interest about things
14. Feeling everything is an error
15. Feeling of worthlessness
TOTAL