| Please answer each of the questions below so we can get an accurate assessement of your current level of anxiety. |
| Answer each question with one of the following: 0=Not at all 1=Somewhat 2=Moderately 3=A lot when completed add your score and let your therapist know at the next appointment, CATEGORY I: ANXIOUS FEELINGS 1. Anxiety, nervousness, worry, or fear._____ 2. Feeling that things around you are strange, unreal, or foggy. _____ 3. Feeling detached from all or part of your body. _____ 4. Sudden unexpected panic spells. _____ 5. Apprehension or a sense of impending doom. _____ 6. Feeling tense, stressed, "uptight," or on edge. _____ CATEGORY II: ANXIOUS THOUGHTS 7. Difficulty concentrating. _____ 8. Racing thoughts or having your mind jump from one thing to the next. _____ 9. Frightening fantasies or daydreams. _____ 10. Feeling that you're on the verge of losing control. _____ 11. Fears of cracking up or going crazy. _____ 12. Fears of fainting or passing out. _____ 13. Fears of physical illnesses or heart attacks or dying. _____ 14. Concerns about looking foolish or inadequate in front of others. _____ 15. Fears of being alone, isolated, or abandoned. _____ 16. Fears of criticism or disapproval. _____ 17. Fears that something terrible is about to happen. _____ CATEGORY III: PHYSICAL SYMPTOMS 18. Skipping or racing or pounding of the heart (sometimes called "palpitations"). _____ 19. Pain, pressure, or tightness in the chest. _____ 20. Tingling or numbness in the toes or fingers. _____ 21. Butterflies or discomfort in the stomach. _____ 22. Constipation or diarrhea. _____ 23. Restlessness or jumpiness. _____ 24. Tight, tense muscles. _____ 25. Sweating not brought on by heat. _____ 26. A lump in the throat. _____ 27. Trembling or shaking. _____ 28. Rubbery or "jelly" legs. _____ 29. Felling dizzy, lightheaded, or off balance. _____ 30. Choking or smothering sensations or difficulty breathing. _____ 31. Headaches or pains in the neck or back. _____ 32. Hot flashes or cold chills. _____ 33. Feeling tired, weak, or easily exhausted. _____ Total Anxiety Score ______ |
| Total Score Degree of Anxiety 0 - 4 Minimal or no anxiety 5 - 10 Borderline anxiety 11 - 20 Mild anxiety 21 - 30 Moderate anxiety 31 - 50 Severe anxiety 51 - 99 Extreme anxiety |