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Anxiety Disorders Screening

Please take a few minutes to complete the following statements. The answers may help your doctor to better understand your health. This questionnaire offers you choices. There are no right or wrong answers. Simply check the circle next to the choice that best describes the way you felt during the past week. Take as long as you like to give the most honest answer.

Once you've answered the questions, please print this out and bring it to your next appointment.

 None or a little of the time Some of the time Good part of the time Most or all of the time
1. I feel more nervous and anxious than usual
2. I feel afraid for no reason at all
3. I get upset easily or feel panicky
4. I feel like I'm falling apart and going to pieces
5. I feel that everything is all right and nothing bad will happen
6. My arms and legs shake and tremble
7. I am bothered by headaches, neck and back pains
8. I feel weak and get tired easily
9. I feel calm and can sit still easily
10. I can feel my heart beating fast
11. I am bothered by dizzy spells
12. I have fainting spells or feel faint
13. I can breathe in and out easily
14. I get feelings of numbness and tingling in my fingers, toes
15. I am bothered by stomachaches or indigestion
16. I have to empty my bladder often
17. My hands are usually dry and warm
18. My face gets hot and blushes
19. I fall sleep easily and get a good night's rest
20. I have nightmares

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