Symptom Management Worksheet
[Pages:2]Symptom Management Worksheet Current Symptoms Self-Report Form
Week of:
Step 1: Get the Right Attitude
InstWrucrtiitoensd:oPwlenasaencyhetchkotuhgehrtesspthoantsemniegxhtttobeeadchiscitoeumratghiantgbeysotudetsocrtirbyessyyomupr tboemhavmioarndaugreimngetnhte.pUasstewyeoeku.r thought-balancing and other skills to rewrite these thoughts.
Unhelpful Thought:
NNeevwerHorelpful Thought:
Rarely Sometimes
Often
Very Often
1
Fail to give close attention to details or make careless mistakes in my work
2 Fidget with hands or feet or squirm in seat
3
Have difficulty sustaining my attention in tasks or fun activities
4
Leave my seat in situations in which seating is expected
5 Don't listen when spoken to directly
6StepF2ee:lIrdeestnletisfsy the Problem and Think about Your Goals
7
Dona't.fWollohwatthsyromugphtoomn sin(sotrruscitdioenes ffanedctfsa)ildtoo you have that are most troubling?
finish work
8
Have difficulty engaging in leisure activities or doing fun things quietly
9 Have difficulty organizing tasks and activities
10 Feel "on the go" or "driven by a motor"
11
Avoid, dislike, or am reluctant to engage in work that
requbir.esIfsuysotauinceodumldenptaicl keffoonrtly one symptom to change, what would it be?
12 Talk excessively
13 Lose things necessary for tasks or activities
Blurt out answers before questions have been
14 completed
c. What would be an initial goal for this symptom? List a concrete, specific change you'd like to 15 Am eassielye.diYsotruacmtedight need to measure your "baseline" before you can determine how much change 16 Have dyiffioucu'dltlyikawe.aiting turn
17 Am forgetful in daily activities
18 Interrupt or intrude on others
From R. A. Barkley & K. R. Murphy (1998), Attention-Deficit Hyperactivity Disorder: A clinical workbook (2nd ed.). New York: Guilford Press. Reprinted with permission.Mastery
Treatments
That
TM
Work
Minding
the
Body
Copyright ? 2005 Oxford University Press
Current Symptoms Self-Report Form
Week of:
Step 3: List Specific Options to Achieve Your Goal Ins(tBruectsiounrse: tPolecahseecckhetchkethsyemrepsptoomnsemnaexntatgoemeaechntitseumggthesattiobensst idnestchriibsecshyaoputrerb.e)havior during the past week.
1.
2.
31.
Fail to give close attention to details or make careless mistakes in my work
Never or Rarely Sometimes
Often
Very Often
2 Fidget with hands or feet or squirm in seat
4.
3
5.
Have difficulty sustaining my attention in tasks or fun activities
4
6.
Leave my seat in situations in which seating is expected
5 Don't listen when spoken to directly
Step 4: Choose the Best Option
6 Feel restless
Consider the pros and cons, impact on self and others, and probability of success.
7
Don't follow through on instructions and fail to finish work
8
Have difficulty engaging in leisure activities or doing fun things quietly
S9tep H5:aIvme dpilffiemcuenltyt tohrgeaOnipzitniogntaasknsdanEdvaalcutiavtietietshe Outcome
10 Feeal ."oWn htheeng,ow" horer"ed,riavnendbhyoawmwotiollr"you try out this new strategy?
11
Avoid, dislike, or am reluctant to engage in work that requires sustained mental effort
12 Talk excessively
13 Lose things necessary for tasks or activities
Blurt out answers before questions have been 14 completed
15 Ambe.asHseileyowdifiswittriaclclhteyadonugeksnoovweriftimit eis. working? Think about how you can self-monitor this symptom to
16 Have difficulty awaiting turn
17 Am forgetful in daily activities
18 Interrupt or intrude on others
From R. A. Barkley & K. R. Murphy (1998), Attention-Deficit Hyperactivity Disorder: A clinical workbook (2nd ed.). New York: Guilford Press. Reprinted with permission.Mastery
Treatments
That
TM
Work
Minding
the
Body
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