Anxiety Questionnaire

Please answer this questionnaire honestly as it will help to assess possible issues you may have with anxiety.  Please count the number of "yes" responses to the following questions:

In the last two weeks, have you experienced:

1. Feelings of nervousness and feeling like you can not relax?
2. Chills or hot flashes unrelated to the weather or any medical condition?
3. A fear of "losing control"?
4. Feeling lightheaded or dizzy?
5. Chest pains or a feeling of tightness in your chest not due to a medical condition?
6. Accelerated heart rate or palpitations?
7. Shaking (especially hands) or trembling?
8. Ruminations, worrying, or intrusive thoughts?
9. Perspiring (sweating) for no apparent cause?
10. Intense fear of dying that lasts for a relatively short period of time?
11. Feeling unsteady or wobbly in your legs especially when you are walking?
12. Feeling afraid the majority of your day?
13. Difficulty breathing or feeling as if you are choking?
14. Stomach or digestive discomfort?

If you have experienced five or more of the previous symptoms during a two-week period you may have anxiety. We encouraged you to consult with a health care provider regarding the questions you answered “yes” to, or you can contact a therapist on this website for a full evaluation and treatment plan.