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Adolescent self-assessment

Adolescent self-assessment tool

Name*

Email address*

Contact number

Location*

Over the past two weeks:

Have you felt there is no hope?
Yes
No

Have you felt guilty all the time?
Yes
No

Have you felt bad about yourself or that you have let others down?
Yes
No

Have you felt that your pain and suffering is unmanageable?
Yes
No

Have you battled to sleep at night? Or have you been sleeping too much?
Yes
No

Have you experienced loss of appetite or unintentional weight loss/gain?
Yes
No

Has your enjoyment of things that you used to enjoy decreased?
Yes
No

Have you felt trapped, helpless and alone?
Yes
No

Have there been times when you have a lot of energy and times when you have none?
Yes
No

Have there been vast variation in the quality or quantity of the work that you have produced?
Yes
No

Have you experienced difficulty concentrating on normal daily tasks e.g. cooking or reading?
Yes
No

Have you suffered a trauma?
Yes
No

Has someone raised concern about your drinking or drugging?
Yes
No

Have you ever stayed away from school, work, college, or university due to drinking or drugging?
Yes
No

Is your drinking or drugging affecting your relationships?
Yes
No

Have you ever felt guilty about your behaviour when drinking or drugging?
Yes
No

Do you drink or drug to escape your worries or troubles?
Yes
No

Have you ever gotten into financial difficulties because of drinking or drugging?
Yes
No

Has your ambition or drive decreased since drinking or drugging?
Yes
No

Is drinking or drugging jeopardising your job or business?
Yes
No

Have you ever had memory loss due to drinking or drugging?
Yes
No

Do you drink/take drugs to build up your self- confidence?
Yes
No

Have you ever tried to control, reduce, or stop your drinking or drugging?
Yes
No

Have you come into contact with the police/legal services due to your drinking or drugging?
Yes
No

Have you needed to increase your drinking or drug quantity to achieve the desired effect?
Yes
No

Have you continued to use alcohol or drugs in situations where it puts yourself/others at risk e.g. whilst driving?
Yes
No

Do you eat only “safe” foods, low in calories and fat?
Yes
No

Have you developed rituals with food, such as cutting food into small pieces or measuring food?
Yes
No

Do you spend more time playing with food than eating it?
Yes
No

Have you felt the need to exercise excessively, after or before eating?
Yes
No

Do you dress in layers to hide weight loss or weight gain?
Yes
No

Have you been spending less time with family and friends?
Yes
No

Do your eating habits interrupt your daily functioning, e.g. eating out with friends, or attending a social function?
Yes
No

Do you spend a lot of time thinking about and planning what you can eat?
Yes
No

Do you make trips to the bathroom after meals?
Yes
No

Do you take laxatives or diuretics after meals?
Yes
No

Are you eating faster than other people?
Yes
No

Have you ever stolen or hoarded food?
Yes
No

Do you perceive yourself as fat despite others saying otherwise?
Yes
No

Is your self-confidence based on your weight?
Yes
No

Do you weigh yourself constantly?
Yes
No

Do you feel guilty after you have eaten?
Yes
No

Is your BMI (body mass index) lower than 18? BMI = (weight) (height squared)
Yes
No

Do you feel you spend many hours a day and many days a week worrying about events or activities e.g. work or school performance?
Yes
No

Are you finding it difficult to control your worrying thoughts?
Yes
No

Does your worrying result in restlessness or feeling tense, on a daily basis?
Yes
No

Is it difficult to concentrate on tasks because your worrying thoughts interfere?
Yes
No

Do you or others find yourself easily irritable?
Yes
No

Do your muscles or body feel tense from stress?
Yes
No

Are you struggling to sleep at night (battling to fall asleep, waking up often, or having restless sleep)?
Yes
No

Is your worrying interrupting your daily activities or relationships?
Yes
No

Have you noticed any of these traits in yourself/your teenager?

Distancing from the family
Yes
No

Lying
Yes
No

Isolating
Yes
No

Drop in academic performance
Yes
No

School refusing
Yes
No

Poor grooming and dress
Yes
No

Negative mood or attitude
Yes
No

New friends (wrong crowd)
Yes
No

Lack of motivation
Yes
No

Self-destructive behaviour
Yes
No

Suicidal ideas
Yes
No

Anger outbursts
Yes
No

Drug use
Yes
No

Cutting/self-harming
Yes
No

Sexual promiscuity
Yes
No

Running away
Yes
No

Alcohol abuse
Yes
No

Lack of self-esteem
Yes
No

Parental distrust
Yes
No

Refusal to eat/overeating
Yes
No

Manipulative and deceitful behaviour
Yes
No

Results

Answers: Yes: | No:
Unanswered:

Based on your answers, we recommend that you check 'Yes' so that we may call/email you with further assistance. If you would like us to get in touch, please check 'Yes' so that we may call/email you with further assistance. Alternatively, call us on 0861 4357 87 .

Yes, please email me
Yes, please call me
Yes, please email me
Yes, please call me

Contact number

No thank you No thank you

Related disorders

Adolescent disorders

Other disorders

Ageing disorders Anxiety disorders Bipolar mood disorder Depression Eating disorders Postnatal depression/Postpartum psychosis Post-traumatic stress disorder Substance abuse / Addiction

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76 Maude Street,
Corner West Street,
Sandton,
2196

Private Bag X34,
Benmore,
2010

Tel: +27 11 301 0000
Fax: +27 11 301 0439

GPS: -26.104922, 28.055648

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