Burns Inventory Checklist for Children

MM slash DD slash YYYY
MM slash DD slash YYYY
Instructions: Circle the number in the column that best describes how you are feeling during the past week, including today. Then write the value of the number in the gray column.

Depression

1. Sad or down in the dumps
2. Discouraged or hopeless (things are not going to get better)
3. Low self esteem (not proud of myself)
4. Worthlessness or inadequate (not good enough)
5. Loss of pleasure or satisfactions ( things are not fun)
6. Do you have thought about suicide?
7. Would you like to end your life?

Panic

1. Sudden feeling of terror or over whelming fear
2. Sudden, terrifying panic attacks that come out of the blue
3. Suddenly feeling you're going crazy or cracking up
4. Suddenly feeling you are about to suffocate or pass out
5. Suddenly feeling you'll have a stroke, heart attack or die

Anger

1. Frustrated
2. Annoyed
3. Resentful
4. Angry
5. Irritated

Anxiety

1. Anxious
2. Frightened
3. Worrying about things over and over
4. Tense or on edge
5. Nervous