Burns Inventory Checklist for Children Name: DOB: MM slash DD slash YYYY Date: 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.Depression1. Sad or down in the dumps Not at all Somewhat Moderately A lot Extremely 2. Discouraged or hopeless (things are not going to get better) Not at all Somewhat Moderately A lot Extremely 3. Low self esteem (not proud of myself) Not at all Somewhat Moderately A lot Extremely 4. Worthlessness or inadequate (not good enough) Not at all Somewhat Moderately A lot Extremely 5. Loss of pleasure or satisfactions ( things are not fun) Not at all Somewhat Moderately A lot Extremely 6. Do you have thought about suicide? Not at all Somewhat Moderately A lot Extremely 7. Would you like to end your life? Not at all Somewhat Moderately A lot Extremely Panic1. Sudden feeling of terror or over whelming fear Not at all Somewhat Moderately A lot Extremely 2. Sudden, terrifying panic attacks that come out of the blue Not at all Somewhat Moderately A lot Extremely 3. Suddenly feeling you're going crazy or cracking up Not at all Somewhat Moderately A lot Extremely 4. Suddenly feeling you are about to suffocate or pass out Not at all Somewhat Moderately A lot Extremely 5. Suddenly feeling you'll have a stroke, heart attack or die Not at all Somewhat Moderately A lot Extremely Anger1. Frustrated Not at all Somewhat Moderately A lot Extremely 2. Annoyed Not at all Somewhat Moderately A lot Extremely 3. Resentful Not at all Somewhat Moderately A lot Extremely 4. Angry Not at all Somewhat Moderately A lot Extremely 5. Irritated Not at all Somewhat Moderately A lot Extremely Anxiety1. Anxious Not at all Somewhat Moderately A lot Extremely 2. Frightened Not at all Somewhat Moderately A lot Extremely 3. Worrying about things over and over Not at all Somewhat Moderately A lot Extremely 4. Tense or on edge Not at all Somewhat Moderately A lot Extremely 5. Nervous Not at all Somewhat Moderately A lot Extremely
