Self Reporting
This form can be printed below or follow this link to download and print.
Stop Antidepressant Damage • Harmed.LifeSpouses & loved ones exposing the truth Big Pharma tries to hide.
Stop Antidepressant Damage
How I Feel — Self-Report (for the person taking/withdrawing from medication)
Mood & Emotions — Rate Today
Circle or mark a number: 1 = Very Low / Better • 3 = Typical • 5 = Very High / Worse
| Area | 1 | 2 | 3 | 4 | 5 |
|---|---|---|---|---|---|
| Sadness / depression | 1 | 2 | 3 | 4 | 5 |
| Anxiety / panic | 1 | 2 | 3 | 4 | 5 |
| Emotional range vs. numbness/blunting | 1 | 2 | 3 | 4 | 5 |
| Irritability / anger | 1 | 2 | 3 | 4 | 5 |
| Restlessness / can’t sit still (akathisia-like) | 1 | 2 | 3 | 4 | 5 |
| Impulsivity / risk-taking urges | 1 | 2 | 3 | 4 | 5 |
| Suicidal thoughts (frequency/intensity) | 1 | 2 | 3 | 4 | 5 |
If any of the above are at 4-5, consider sharing this page with someone you trust and your prescriber.
Functioning & Daily Life
| Area | 1 | 2 | 3 | 4 | 5 |
|---|---|---|---|---|---|
| Sleep quality | 1 | 2 | 3 | 4 | 5 |
| Energy / fatigue | 1 | 2 | 3 | 4 | 5 |
| Motivation / drive | 1 | 2 | 3 | 4 | 5 |
| Enjoyment / interest (anhedonia) | 1 | 2 | 3 | 4 | 5 |
| Memory / focus / thinking speed | 1 | 2 | 3 | 4 | 5 |
| Judgment (making sound choices) | 1 | 2 | 3 | 4 | 5 |
| Decisions (daily decisions feel manageable) | 1 | 2 | 3 | 4 | 5 |
| Money choices (spending, risk, impulse buys) | 1 | 2 | 3 | 4 | 5 |
| Relationships (connection, communication) | 1 | 2 | 3 | 4 | 5 |
| Empathy (ability to feel with others) | 1 | 2 | 3 | 4 | 5 |
| Warmth (affection, kindness, intimacy) | 1 | 2 | 3 | 4 | 5 |
| Work/school functioning | 1 | 2 | 3 | 4 | 5 |
Body & Side Effects (check any that apply)
Stop Antidperessant Damage
How I Feel — Self-Report (continued)
Medication Changes & Withdrawal
What I Wish My Loved Ones & Clinician Knew
My Safety & Support Plan (optional)
Add your local crisis line or emergency contacts here so this page can help in a tough moment.
Permission to Share
Signature
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