HOPKINS SYMPTOMS CHECKLIST

NAME: DALE ANTHONY B. MALIJAN AGE: 20 SEX: MALE DATE: 09-14-

2021

INSTRUCTIONS:
Listed below are symptoms or problems that people sometimes have. Please read each one carefully and decide how
much the symptoms bothered or distressed you in the last week, including today. Please put a check (✓) in the appropriate
column.
Nakasulat sa ibaba ang ilang simtomas o problema na nararanasan ng isang tao paminsan-minsan. Basahin ang
bawat linya ng maigi at ipahayag kung gaano ka nabagabag noong isang lingo kasama na rin ang ngayon.

PART I: “A” SYMPTOMS

(1) (2) (3) (4)

SYMPTOMS NOT AT ALL A LITTLE QUITE A BIT EXTREMELY
MGA SIMTOMAS HINDI BIHIRA MADALAS MATINDI
1. Suddenly scared for no reason ✓
Biglang natatakot ng walang dahilan
2. Feeling Fearful ✓
Nakakaramdam na may masamang
mangyayari
3. Faintness, dizziness, weakness ✓
Nanghihina, nahihilo, parang hihimatayin
4. Nervousness or shakiness ✓
Ninenerbiyos o nanginginig
5. Heart pounding or racing ✓
Kinakabahan ng matindi
6. Trembling ✓
Panginginig o pangangatog
7. Feeling tensed or keyed up ✓
Hindi makagalaw, naninigas ang katawan
8. Headache ✓
Pananakit ng ulo
9. Spells of terror or panic ✓
Biglang pagdanas ng matinding takot at
pagkataranta
10. Feeling restless, can’t sit still ✓
Hindi mapakali o mapalagay
7 4 6 0
TOTAL

TOTAL RAW SCORE: 17 OVERALL SCORE: 1.7

COMMENTS/INTERPRETATION:
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1
 PART II: “D” SYMPTOMS

(1) (2) (3) (4)

SYMPTOMS NOT AT ALL A LITTLE QUITE A BIT EXTREMELY
MGA SIMTOMAS HINDI BIHIRA MADALAS MATINDI
1. Feeling low in energy ✓
Pananamlay
2. Blaming yourself for things ✓
Sinisisi ang sarili sa mga pangyayari
3. Crying easily ✓
Madaling maiyak
4. Loss of sexual interest or pleasure ✓
Walang gana makipagtalik
5. Poor appetite ✓
Walang gana kumain
6. Difficulty falling/staying asleep ✓
Hirap makatulog
7. Feeling hopeless about the future ✓
Kawalan ng pag-asa sa hinaharap
8. Feeling blue ✓
Malungkot
9. Feeling lonely ✓
Nangungulila
10. Thoughts of ending your life ✓
Gustong magpakamatay
11. Feeling being trapped or caught ✓
Pakiramdam ay nakakulong
12. Worrying too much about things ✓
Labis na pag-aalala
13. Feeling no interest about things ✓
Walang gana sa kahit ano
14. Feeling everything is an effort ✓
Nahihirapang gumalaw o kumilos
15. Feeling of worthlessness ✓
Pakiramdam na walang kwenta
6 14 6 0
TOTAL

TOTAL RAW SCORE: 26 OVERALL SCORE: 1.73

COMMENTS/INTERPRETATION:
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