Concurrent Disorder refers to any psychiatric condition that may occur in a person with addiction or in recovery from addiction.

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1 Concurrent Disorder refers to any psychiatric condition that may occur in a person with addiction or in recovery from addiction. This self report Symptom Inventory will provide your doctor with basic information about your emotional symptoms - and that may or may not indicate a concurrent psychiatric disorder. You may print this inventory and then checkmark the boxes. Complete the Symptom Inventory by checking each statement that describes your experience. Do not checkmark any statement that does not describe you. We suggest that you write your name on this form only after you have arrived at your doctor s office. During interview with your doctor or counselor, you will have opportunity to discuss your symptoms in greater detail. Set Symptom Inventories are not diagnostic of any specific psychiatric disorder. This form is intended only to help you better communicate your symptoms to a doctor or qualified health professional. My ame is: I am years old. I live in: specify I am: Single Married Common law committed I live with: Family Friends I live on my own. I am currently: Employed Unemployed Disabled I s myself with: Personal finances A disability pension Other Social S

2 My goal in attending this assessment is: The following statements describe thoughts, feelings and habits. If a statement describes your overall experience during the past one month - please indicate so with a checkmark. If a statement does not apply to yourself, you may leave the checkbox blank. Please check all that apply: My mood is okay most of the time My mood is low some of the time My mood is very low most of the time I sometimes feel anxious I do not have a problem with anxiety I feel anxious most of the time I become anxious when around people I have episodes of panic anxiety I avoid places due to anxiety I avoid people due to anxiety

3 Please check all that apply to your overall experience during the past one month: I avoid going outside due to anxiety I worry a lot of the time I often feel nervous, jittery or shaky I feel fearful much of the time I have difficulty concentrating I am easily distracted I have difficulty sitting still for long I have trouble finishing projects I start too many things at once I have difficulty organizing things I often feel stressed out I feel stressed in busy surroundings I have tension headaches I grind my teeth I often have a stiff neck My energy is okay most of the time My energy is poor most of the time I have no enegy

4 Please check all that apply to your overall experience during the past one month: My mood changes frequently My mood changes without warning My mood may change often in a day My mood often shifts between extremes My mood has been elevated or My mood has been irritable I have been easily frustrated high I have not required much sleep I have made too many plans I have had an increase in sexual energy I have had increased overall energy My sleep is okay My sleep is poor I have trouble falling asleep I wake up often in the night I wake up too early in the morning I sleep during the daytime I sleep too much

5 Please check all that apply to your overall experience during the past one month: I have had several nightmares I often wake up frightened I often recall past traumas I have intrusive memories of trauma I have flashbacks I am running from painful memories I am running from painful feelings My feelings often shut off I often feel bored or empty inside I sometimes hurt myself on purpose I have cut myself IfeelIam coming apart at the seams I often feel unreal and out of myself I often feel that life is not worth living I have felt like ending my life I have felt suicidal I have tried to hurt myself on purpose I have tried to kill myself

6 Please check all that apply to your overall experience during the past one month: I often check things over and over I clean so much that it is a problem I find myself counting things often I have recurrent, intrusive thoughts I starve myself to lose weight I make myself throw up to lose weight I exercise excessively to lose weight My mood is much lower during winter My appetite is increased during winter My energy is far lower during winter I sleep excessively during winter I hear voices that I cannot explain I fear that my mind is being controlled I fear that others are trying to harm me Other people can hear my thoughts I can hear the thoughts of others My activities are being monitored I believe that I may be losing my mind

7 Please check all that apply to your family of origin: I grew up with my biological family I grew up with my adoptive family I have a close relative with alcoholism I have a close relative with addiction I have a close relative with depression I have a relative with manic-depression I have a relative with anxiety I have a relative with panic attacks I have a relative with agoraphobia My mother was emotionally well My mother had episodes of depression My mother had an alcohol problem My mother had a drug problem My father was emotionally well My father had episodes of depression My father had an alcohol problem My father had a drug problem

8 Please check all that apply to personal history I mostly have fond childhood memories I grew up in a comfortable home My parents were kind to me I always had many friends I tended to have one or two friends I tended to be a loner I was bullied and/or teased as a child I bullied and/or teased others I did well at school I was often in trouble at school I have my high school diploma I had trouble learning at school I had trouble concentrating at school I was often punished at school I was diagnosed with attention deficit I was depressed as a child I was troubled as a child I always felt different from others

9 Please check all that apply to personal history I have never experienced abuse I believe that I was abused as a child I was physically abused/hurt as a child I was sexually abused/hurt as a child I was mentally abused/hurt as a child I have enjoyed an adult relationship I have been treated well in relationships I have been with an abusive partner I have been with an alcoholic partner I have been with an addicted partner I have experienced other traumas I have been taken advantage of I care more for others than myself I am in a relationship now I am in a healthy relationship now I am in an abusive relationship now I am in a troubled relationship now I am in an unhealthy relationship now

10 Please check all that apply to anytime in your life history: I have seen a psychiatrist before I have had treatment for depression I have had treatment for anxiety I have had treatment for psychosis I have been hospitalized in psychiatry I have attempted suicide I have cut or hurt myself purposely I have been diagnosed with: Clinical Depression Bipolar (Manic) Depression Panic Disorder Agoraphobia General Anxiety Disorder Schizophrenia Post Traumatic Stress Disorder Attention Deficit Disorder Eating Disorder Other

11 Please checkmark any of the following medications that you have ever taken by prescription: Paxil, Prozac, Zoloft or Luvox Serzone, Effexor, Celexa or Remeron Lithium Carbonate Valproic Acid, Epival or Carbamazepine Topamax Chlorpromazine or ozinan Stelazine, Perphenazine or Haldol Zyprexia, Olanzapine, Rispiridol Ritalin, Cylert, or other Amphetamine Valium, Ativan, Clonazepam Serax, Alprazolam Amitriptyline, Trazadone, Doxepin Other I have allergies to the following medications: