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WC English (cont.)

Behavioral Health Symptom Checklist & Treatment

I. Pyschological Problems

1. I often feel angry and/or irritable
2. I often feel very nervous and/or anxious and/or frightened
3. I often feel depessed and/or hopeless and/or cry often
4. I often feel very moody and can't control my emotions
5. I often have problems sleeping through the night
6. I'm always tired and all I want to do is sleep
7. I have thoughts of harming/hurting myself and/or suicide
8. I have been havig problems and arguments more often at home with my family, spouse, or children
9. I often feel people are talking about meand staring at me
10. I have frequent thoughts about flashbacks or nightmares about the accident and/or about other kinds of accidents
11. I am afraid to drive, be in a car, or be near moving cars
12. I am afraid to leave the house or come into contact with other people
13. I have had a change in my appetite
14. I have lost my interest in having relations with my partner
15. I am having many headaches and/or feel dizzy and/or have blurred vision and/or problem with balance

II. Cognitive Problems

1. I am more forgetful and my memory has gotten worse
2. I feel more confused and forget where I have to go or what I have to do
3. I feel I can't make decisions or solve problems like I used to
4. I feel my thoughts are all mixed up and I can't think straight
5. I am having problems with directions and often get lost
6. I can't speak or say what I want; the words don't come out the way I want
7. I can't concentrate or pay attention to things like I used to


Based on the symptoms I have checked off, I am voluntarily requesting to be evaluated regarding treatment for my complaints.

Thanks for submitting!

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