Christian Counseling Professionals

BURNS DEPRESSION CHECKLIST
Read each statement and place the appropriate number next to it:
0 - Not at all
1 - Somewhat
2 - Moderately
3 - A lot
     (Fill all fields then click Submit at bottom)

Patient Name:

A. Saddness: Do you feel sad or down in the dumps?

B. Discouragement: Does your future look hopeless?

C: Low Self-Esteem: Do you feel worthless?

D. Inferiority: Do you feel inadequate or inferior to others?

E. Guilt: Do you get self-critical and blame yourself?

F. Indecisiveness: Is it hard to make decisions?

G. Irritability: Do you frequently feel angry or resentful?

H. Loss of interest in life: Have you lost interest in your in your career, hobbies, family and friends?

I. Loss of motivation: Do you have to push yourself to do things?

J. Poor Self-Image: Do you feel old and unattractive?

K. Appetite Changes: Have you lost your appetite? Do you overeat or binge compulsively?

L. Sleep Changes: Is it hard to get at good night's sleep? Are you excessively tired and sleeping too much?

M. Concerns about Health: Do you worry excessively about your health?

N. Suicidal Impulses? Do you have thoughts that life is not worth living or think you'd be better off dead?

TOTAL SCORE FOR THE BURNS DEPRESSION CHECKLIST

The Burns Anxiety Inventory Please select which number applies to you in the box to the right of each category to indicate how much this type of feeling has bothered you in the past several days. None = 0 Somewhat = 1 Moderate = 2 A lot = 3

               Category I: Anxious Feelings

1. Anxiety, nervousness, worry or fear

2. Feeling that things around you are strange or unreal

3. Feeling detached from all or part of your body

4. Sudden unexpected panic spells

5. Apprehension or a sense of impending doom

6. Feeling tense, stressed, "uptight", or on edge

               Category II: Anxious Thoughts

7. Difficulty concentrating

8. Racing Thoughts

9. Frightening fantasies or daydreams

10. Feeling that you're on the verge of losing control

11. Fears of cracking up or going crazy

12. Fears of fainting or passing out

13. Fears of physical illness or heart attacks or dying

14. Concerns about looking foolish or inadequate

15. Fears of being alone, isolated, or abandoned

16. Fears of criticism or disapproval

17. Fears that something terrible is about to happen

               Category III: Physical Symtoms

18. Skipping, pounding, or racing heart

19. Pain, pressure, or tightness in the chest

20. Tingling or numbness in the toes or fingers

21. Butterflies or discomfort in the stomach

22. Constipation or diarrhea

23. Restlessness or jumpiness

24. Tight, tense muscles

25. Sweating not brought about by heat

26. A lump in the throat

27. Trembling or shaking

28. Rubbery or "jelly" legs

29. Feeling dizzy, light-headed or off-balance

30. Choking, smothering sensations/difficulty breathing

31. Headaches or pain in the back of the neck

32. Hot flashes or cold chills

33. Feeling weak, tired , or easily exhausted
               Reference: Ten Days to Self-Esteem, David D. Burns

TOTAL SCORE FOR ITEMS 1-33

The Mood Disorder Questionnaire- Please answer "yes" or "no" Has there ever been a time when you were not your usual self and ...

A.... you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?

B...you were so irritable that you shouted at people or started fights or arguments?

C...you felt more self-confident than usual?

D...you got much less sleep than usual and found you didn't really miss it?

E...you were much more talkative or spoke much faster than usual?

F...thoughts raced through your head or you couldn't slow your mind down?

G...you were easily distracted by things around you that you had trouble concentrating or staying on track?

H...you had much more energy than usual?

I...you were much more active or did many more things than usual?

J...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?

K...you were much more interested in sex than usual?

L...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?

M...spending money that got you or your family into trouble?

N. If you selected "YES" to more than one of the above, have several of these ever happened during the same period of time?

O.How much of a problem did any of these cause you- like being unable to work, having family, money, or legal troubles; getting into arguments or fights? Please select one response only: no problem, minor problem, moderate problem, severe problem

TOTAL OF "Yes" RESPONSES

               Adult Self-Report Scale (ASRS) Symptom Checklist
Please answer the questions below, rating yourself on each of the criteria by selecting one of the responses from the drop-down list on the right. As you answer each question, circle the correct number that best describes how you have felt and conducted yourself over the past 6 months.
Please rate from 0-4, never=0 rarely=1 sometimes=2 often=3 very often= 4

1. How often do you make careless mistakes when you have to work on a boring or difficult project?

2. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?

2. How often do you have difficulty keeping your attention when you are doing boring or repetitive work? 3. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?

4. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?

5. How often do you have difficulty getting things in order when you have a task to do that requires organization?

6. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?

7. How often do you misplace or have difficulty finding things at home or at work?

8. How often are you distracted by activity or noise around you?

9. How often do you have problems remembering appointments or obligations?

10. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?

11. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?

12. How often do you feel restless or fidgety?

13. How often do you have difficulty unwinding and relaxing when you have time to yourself?

14. How often do you feel overly active and compelled to do things, like you were driven by a motor?

15. How often do you find yourself talking too much when you are in a social situation?

16. When you're in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?

17. How often do you interrupt others when they are busy?

TOTAL FOR ITEMS 1-17

A. Saddness: Do you feel sad or down in the dumps?
B. Discouragement: Does your future look hopeless?
C: Low Self-Esteem: Do you feel worthless?
D. Inferiority: Do you feel inadequate or inferior to others?
E. Guilt: Do you get self-critical and blame yourself?
F. Indecisiveness: Is it hard to make decisions?
G. Irritability: Do you frequently feel angry or resentful?
H. Loss of interest in life: Have you lost interest in your in your career, hobbies, family and friends?
I. Loss of motivation: Do you have to push yourself to do things?
J. Poor Self-Image: Do you feel old and unattractive?
K. Appetite Changes: Have you lost your appetite? Do you overeat or binge compulsively?
L. Sleep Changes: Is it hard to get at good night's sleep? Are you excessively tired and sleeping too much?
M. Concerns about Health: Do you worry excessively about your health?
N. Suicidal Impulses? Do you have thoughts that life is not worth living or think you'd be better off dead?
TOTAL SCORE FOR THE BURNS DEPRESSION CHECKLIST

Category I: Anxious Feelings
1. Anxiety, nervousness, worry or fear
2. Feeling that things around you are strange or unreal
3. Feeling detached from all or part of your body
4. Sudden unexpected panic spells
5. Apprehension or a sense of impending doom
6. Feeling tense, stressed, "uptight", or on edge
Category II: Anxious Thoughts
7. Difficulty concentrating
8. Racing Thoughts
9. Frightening fantasies or daydreams
10. Feeling that you're on the verge of losing control
11. Fears of cracking up or going crazy
12. Fears of fainting or passing out
13. Fears of physical illness or heart attacks or dying
14. Concerns about looking foolish or inadequate
15. Fears of being alone, isolated, or abandoned
16. Fears of criticism or disapproval
17. Fears that something terrible is about to happen
Category III: Physical Symtoms
18. Skipping, pounding, or racing heart
19. Pain, pressure, or tightness in the chest
20. Tingling or numbness in the toes or fingers
21. Butterflies or discomfort in the stomach
22. Constipation or diarrhea
23. Restlessness or jumpiness
24. Tight, tense muscles
25. Sweating not brought about by heat
26. A lump in the throat
27. Trembling or shaking
28. Rubbery or "jelly" legs
29. Feeling dizzy, light-headed or off-balance
30. Choking, smothering sensations/difficulty breathing
31. Headaches or pain in the back of the neck
32. Hot flashes or cold chills
33. Feeling weak, tired , or easily exhausted
Reference: Ten Days to Self-Esteem, David D. Burns
TOTAL SCORE FOR ITEMS 1-33

A.... you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
B...you were so irritable that you shouted at people or started fights or arguments?
C...you felt more self-confident than usual?
D...you got much less sleep than usual and found you didn't really miss it?
E...you were much more talkative or spoke much faster than usual?
F...thoughts raced through your head or you couldn't slow your mind down?
G...you were easily distracted by things around you that you had trouble concentrating or staying on track?
H...you had much more energy than usual?
I...you were much more active or did many more things than usual?
J...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
K...you were much more interested in sex than usual?
L...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
M...spending money that got you or your family into trouble?
N. If you selected "YES" to more than one of the above, have several of these ever happened during the same period of time?
O.How much of a problem did any of these cause you- like being unable to work, having family, money, or legal troubles; getting into arguments or fights? Please select one response only: no problem, minor problem, moderate problem, severe problem
TOTAL OF "Yes" RESPONSES

Adult Self-Report Scale (ASRS) Symptom Checklist Please answer the questions below, rating yourself on each of the criteria by selecting one of the responses from the drop-down list on the right. As you answer each question, circle the correct number that best describes how you have felt and conducted yourself over the past 6 months. Please rate from 0-4, never=0 rarely=1 sometimes=2 often=3 very often= 4
1. How often do you make careless mistakes when you have to work on a boring or difficult project?
2. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
2. How often do you have difficulty keeping your attention when you are doing boring or repetitive work? 3. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
4. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
5. How often do you have difficulty getting things in order when you have a task to do that requires organization?
6. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
7. How often do you misplace or have difficulty finding things at home or at work?
8. How often are you distracted by activity or noise around you?
9. How often do you have problems remembering appointments or obligations?
10. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
11. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?
12. How often do you feel restless or fidgety?
13. How often do you have difficulty unwinding and relaxing when you have time to yourself?
14. How often do you feel overly active and compelled to do things, like you were driven by a motor?
15. How often do you find yourself talking too much when you are in a social situation?
16. When you're in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?
17. How often do you interrupt others when they are busy?
TOTAL FOR ITEMS 1-17