One Page MH Breif Screen- It is not how many you check or circle it is how much distress, that is emotional pain and suffering and how much impairment that is trouble, they are causing in your self, your body, your relationships at home, at work, or at play, or in the community
Read each item carefully, then 1. CHECK IF the Number APPLIES, THEN 2. CIRCLE the Specific Item to Clarify
1. [ ] Hyperactive, overly active, on the go, can’t sit still, and/or an inner sense of restlessness
2. [ ] Distractible, Sometimes? Mostly? Can’t concentrate, pay attention on boring stuff, for 15 minutes
3. [ ] Impulsive, doesn’t stop and think of consequences before talking or doing, or further thinking
4. [ ] Colicky as infant, presently unpleasant, irritable, nasty, mean, severe tantrums, bossy, the bully
5. [ ] Severe separation anxiety, frequent school absences, migraines, headaches, frequently ill, always sick
5. [ ] Short fuse, easily made angry, can’t calm self down within 20 min, severe temper, rage attacks
6. [ ] Mood swings, unpredictable, ups and downs of feelings, driven by moods, Dr Jekle & Mr.Hyde,
7. [ ] Can’t control anger, breaking things, self mutilating, dangerous to others, talks about killing others
8. [ ] Unaware of time, place, who you are, dazed, lost in time, confused, sleep like, or trance like states
9. [ ] Hurting self, cuts self, punches things, talk of suicide, being better off dead, dangerous to self
10. [ ] Sleep difficulties, sleeps too much/ too little, wakes up, dreams seem real, nightmares, wets bed,
11. [ ] Talks too much, too fast, not logical, difficult to follow, talks in circles, doesn’t always makes sense
12. [ ] Feeling sad, crying, saying negative things, not normal self, easily bored, things are less fun, isolates self
13. [ ] Excessive eating, especially in evening, waking up after asleep and eating, eats to calm down
14. [ ] Overly suspicious, holds grudges paranoid, thoughts seem like voices, odd, bizarre, strange, weird
15. [ ] Too worried, afraid to do things, go places, shy, stage fright, panic attacks, heart beats fast, sweats easily
16. [ ] Excessive eye blinking, facial movements, throat clearing, sniffing, snorting, coughing,
17. [ ] Does things over and over, rituals, touching, counting, hand washing, ordering, putting things in sequence
18. [ ] Gets angry/fearful to change in routines ,sensitivities to, sound, touch, light, taste, smells, foods
19. [ ] Poor eye contact, doesn’t seem to get social things like greetings, jokes, sorrows, need to love, to grieve
20. [ ] Delay or improper use of language, play-pretend get stuck on one idea over, especially sexual, violent
21. [ ] Over use or cant stop using drugs, alcohol, tobacco, exercise, food, TV, video games, computer time
22. [ ] Trouble in reading, spelling, math, other learning problems, speech, stuttering, co ordination difficulties
23. [ ] Witnessed domestic violence, victim of neglect, physical and/or sexual abuse, natural catastrophe
24. [ ] Cruel to animals, cruel to people, nasty, mean, seems to lack conscience, no or little remorse, guilt, shame