Anxiety Questionnaire

Section One: Symptom Frequency Score
0 Never
1 Rarely
2 Sometimes
3 Often
4 Usually
Do you feel afraid or scared?*
- 0 -- Never
- 1 -- Rarely
- 2 -- Sometimes
- 3 -- Often
- 4 -- Usually
Do you experience chest pain or discomfort?*
- 0 -- Never
- 1 -- Rarely
- 2 -- Sometimes
- 3 -- Often
- 4 -- Usually
Do you experience nausea or abdominal discomfort?*
- 0 -- Never
- 1 -- Rarely
- 2 -- Sometimes
- 3 -- Often
- 4 -- Usually
Do you sweat copiously?*
- 0 -- Never
- 1 -- Rarely
- 2 -- Sometimes
- 3 -- Often
- 4 -- Usually
Do you feel dizzy/light headed or unsteady?*
- 0 -- Never
- 1 -- Rarely
- 2 -- Sometimes
- 3 -- Often
- 4 -- Usually
Do you experience fear of losing control or going crazy?*
- 0 -- Never
- 1 -- Rarely
- 2 -- Sometimes
- 3 -- Often
- 4 -- Usually
Do you experience numbness or tingling sensations?*
- 0 -- Never
- 1 -- Rarely
- 2 -- Sometimes
- 3 -- Often
- 4 -- Usually
Do you have a fear of dying?*
- 0 -- Never
- 1 -- Rarely
- 2 -- Sometimes
- 3 -- Often
- 4 -- Usually
Are you having chills or hot flashes?*
- 0 -- Never
- 1 -- Rarely
- 2 -- Sometimes
- 3 -- Often
- 4 -- Usually
Do you have constant or persistent worry?*
- 0 -- Never
- 1 -- Rarely
- 2 -- Sometimes
- 3 -- Often
- 4 -- Usually
Do you have a feeling of choking?*
- 0 -- Never
- 1 -- Rarely
- 2 -- Sometimes
- 3 -- Often
- 4 -- Usually
Do you hands tremble?*
- 0 -- Never
- 1 -- Rarely
- 2 -- Sometimes
- 3 -- Often
- 4 -- Usually
Do you feel you may faint/pass out?*
- 0 -- Never
- 1 -- Rarely
- 2 -- Sometimes
- 3 -- Often
- 4 -- Usually
Do you avoid situations?*
- 0 -- Never
- 1 -- Rarely
- 2 -- Sometimes
- 3 -- Often
- 4 -- Usually
Is it hard to sit still?*
- 0 -- Never
- 1 -- Rarely
- 2 -- Sometimes
- 3 -- Often
- 4 -- Usually
Do you have heart palpitations?*
- 0 -- Never
- 1 -- Rarely
- 2 -- Sometimes
- 3 -- Often
- 4 -- Usually
Do you get enraged or feel irritable?*
- 0 -- Never
- 1 -- Rarely
- 2 -- Sometimes
- 3 -- Often
- 4 -- Usually
Do you have difficulty going to sleep?*
- 0 -- Never
- 1 -- Rarely
- 2 -- Sometimes
- 3 -- Often
- 4 -- Usually
Do you feel nervous?*
- 0 -- Never
- 1 -- Rarely
- 2 -- Sometimes
- 3 -- Often
- 4 -- Usually
Are you unable to relax?*
- 0 -- Never
- 1 -- Rarely
- 2 -- Sometimes
- 3 -- Often
- 4 -- Usually
Do you experience the feeling of being unreal?*
- 0 -- Never
- 1 -- Rarely
- 2 -- Sometimes
- 3 -- Often
- 4 -- Usually
Do you feel shaky or wobbly?*
- 0 -- Never
- 1 -- Rarely
- 2 -- Sometimes
- 3 -- Often
- 4 -- Usually
Are you easily tired?*
- 0 -- Never
- 1 -- Rarely
- 2 -- Sometimes
- 3 -- Often
- 4 -- Usually
Do you have unexplained muscle tension?*
- 0 -- Never
- 1 -- Rarely
- 2 -- Sometimes
- 3 -- Often
- 4 -- Usually
FINAL SCORE
To see your final score and the interpretation of the results, submit this form including your email address, and you will be brought straight to your results screen.
FINAL SCORE
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DO YOU HAVE ANXIETY?

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Section One: Symptom Frequency Score

FINAL SCORE