Mental Symptom Checklist

Name*

First NameFirst and last letter of last name

Email*

example@example.com

Name of person completing the form if applicable*

First NameLast Name

Relationship to applicant

Disabilities

Disability 1*

Year symptoms started*

ie. 2014

Disability 2

Year symptoms started

ie. 2014

Disability 3

Year symptoms started

ie. 2014

Disability 4

Year symptoms started

ie. 2014

How does your medical condition affect you?

Medication and Treatment

Do you take medication for your medical condition*

YesNo

Do you require supervision or reminders to take your medication?*

YesNo

Describe any devices or therapy that you use*

I.e., physical devices, memory aids, alarms, reminders, cognitive-behavioural therapy, physio therapy, massage, chiropractor/physiotherapy, counselling, assistance from friends and family

Select all types of support received - Adult

Assisted living or long-term facilityCommunity-based health servicesHospitalizationSupport from family members

Select all types of support received - Child under 18

Adult supervision at home beyond an age-appropriate levelAdditional support from educational staff at school

Provide DETAILED examples on how you are impacted

Please include examples that have existed since your symptoms first appeared as well as current symptoms*

I.e. Isolates self from others, emotional dysregulation, reduced ability to concentrate, panic attacks, difficulty in public spaces, flashbacks, nightmares, hallucinations

	Severe Limitations	Some Limitations	No Limitations
Adapt to change
Express basic needs
Go out into the community
Initiate common, simple transactions
Perform basic hygiene or self-care activities
Perform necessary, everyday tasks
Demonstrate awareness of danger and risks to personal safety
Demonstrate basic impulse control
Focus on a simple task for any length of time
Absorb and retrieve information in the short-term
Make and carry out simple day-to-day plans
Self-direct to begin everyday tasks
Choose weather-appropriate clothing
Make decisions about their own treatment and welfare
Recognize risk of being taken advantage of by others
Understand consequences of their actions or decisions
Remember basic personal information such as date of birth and address
Remember material of importance and interest to themselves
Remember simple instructions
Demonstrate an accurate understanding of reality
Distinguish reality from delusions and hallucinations
Identify everyday problems
Implement solutions to simple problems
Behave appropriately for the situation
Demonstrate appropriate emotional responses for the situation
Regulate mood to prevent risk of harm to self or others
Understand and respond to non-verbal information or cues
Understand and respond to verbal information

Medical Questionnaire