Denika Y. Douglas, Ph.D. 
Licensed Psychologist (Lic.# 35076)
Licensed Specialist in School Psychology (Lic.# 34421)

4801 Woodway Dr., Suite 300E														    				 (713) 574-8502
Houston, Texas 77056												    			   drdouglas@douglassolutions.com

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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 persons), 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) 
❑ 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 
❑ Grieving, mourning, deaths, losses, divorce 
❑ Guilt 
❑ Headaches, other kinds of pains 
❑ Health, illness, medical concerns, physical problems 
❑ Housework/chores—quality, schedules, sharing duties 
❑ 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, different expectations, disappointments 
❑ Memory problems 
❑ Menstrual problems, PMS, menopause 
❑ Mood swings 
❑ Motivation, laziness 
❑ Nervousness, tension 
❑ Obsessions, compulsions (thoughts or actions that repeat themselves) 
❑ Oversensitivity to rejection 
❑ Pain, chronic
❑ Panic or anxiety attacks 
❑ Parenting, child management, single parenthood 
❑ Perfectionism 
❑ Pessimism 
❑ Procrastination, work inhibitions, laziness 
❑ Relationship problems (with friends, with relatives, or at work) 
❑ 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 
❑ Spiritual, religious, moral, ethical issues 
❑ Stress, relaxation, stress management, stress disorders, tension 
❑ Suspiciousness, distrust 
❑ 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, dissatisfaction, ambition 
❑ Other concerns or issues: ______________________________________________________________________
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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

FORM 29. Adult checklist of concerns. From The Paper Office. Copyright 2003 by Edward L. Zuckerman. Per­mission to photocopy this form is granted to purchasers of this book for personal use only (see copyright page for details).