| This checklist is designed to help people who feel they may be suffering from symptoms of anxiety disorders. It is important to note that this is not a diagnostic instrument. The purpose of the screening questionnaire is to present a wide range of the symptoms of various anxiety disorders so that you can select those which best represent your feelings. During the past month, have you been bothered by (select the appropriate response): |
| YES: | NO: | |
| | 1. An unexpected panic or anxiety attack (suddenly experiencing fear for no apparent reason)? |
| | 2. Persistent, senseless thoughts that you can't get out of your mind (e.g. thoughts of death, aggression, sexual urges or contamination)? |
| | 3. Feeling very uncomfortable in situations involving people (e.g. parties, meetings, dating)? |
| | 4. Persistently worry about several different things? |
| | 5. Being afraid of not being able to get help or escape (e.g. when on a bridge, in a tunnel, or in a crowded store)? |
| | 6. Being afraid to do things in front of people (speaking, eating, performing, etc.)? |
| | 7. Unexplained palpitations (heart racing) or shortness of breath for no apparent reason? |
| | 8. Having a persistent or unreasonable fear when anticipating contact with an object (like insects, snakes, animals, blood, etc.)? |
| | 9. Being afraid to travel alone (i.e. without a companion)? |
| | 10. Doing things over and over again, many more times than is needed (e.g. spending too much time each day washing hands, checking door locks, or counting things)? |
| | 11. Feeling nervous or tense much of the time? |
| | 12. Often have experienced an extremely frightening or traumatic event, like being the victim of a violent crime, seriously injured in an accident, sexually assaulted, seeing someone seriously injured or killed, or been the victim of a natural disaster? |
| | 13. How much of the time does your anxiety interfere with your daily life?
a. Not at all (0%)
b. Rarely (5-10%)
c. Some of the time (20-30%)
d. About half the time (40-60%)
e. Most of the time (70-80%)
f. Almost all the time (90-100%)
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