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Anxiety Screening Questionnaire


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A
nxiety Screening Questionaire

You can print this page and answer the questions in privacy by circling the numbers beside each statement. If the results indicate that you have scored high on the anxiety ontinuum, we recommend you bring the results to your family doctor for further assessment and/or contact us  if you wish to explore therapeutic options.

   
 
Not at All
 
A little
 
Moderately
 
Quite a bit
 
Extremely
1
Difficulty in getting your breath, smothering, or over breathing
0
1
2
3
4
2
Choking sensation or a lump in the throat
0
1
2
3
4
3
Skipping, racing, or pounding of your heart
0
1
2
3
4
4
Chest Pain, pressure, or discomfort
0
1
2
3
4
5
Bouts of excessive sweating
0
1
2
3
4
6
Faintness, light-headedness, or dizzy spells
0
1
2
3
4
7
Sensation of rubbery or "jelly" legs
0
1
2
3
4
8
Feeling off balance or unsteady like you might fall
0
1
2
3
4
9
Nausea or stomach problems
0
1
2
3
4
10 Feeling that things around you are strange, unreal, foggy, or detached from you
0
1
2
3
4
11 Feeling outside or detached from part or all of your body, or a floating freely
0
1
2
3
4
12 Tingling or numbness in parts of your body
0
1
2
3
4
13 Hot flashes or cold chills
0
1
2
3
4
14 Shaking or trembling
0
1
2
3
4
15 Having a fear that you are dying or that something terrible is about to happen
0
1
2
3
4
16 Feeling you are losing control or going insane
0
1
2
3
4
17 Sudden anxiety attacks with three or more of the symptoms listed above that occur when you are in or are about to go into a situation that is likely, from your experience, to bring on an attack
0
1
2
3
4
18 Sudden unexpected anxiety attacks with three or more symptoms listed above that occur with little or no provocation (i.e. when you are NOT in a situation that is likely, from your experience to bring on an attack)
0
1
2
3
4
19 Sudden unexpected spells with only one or two symptoms (listed above) that occur with little or no provocation (i.e. when you are NOT in a situation that is likely , from your experience, to bring on an attack)
0
1
2
3
4
20 Anxiety episodes that build up as you anticipate doing something that is likely, from your experience, to bring on anxiety that is more intense than most people experience in such situations
0
1
2
3
4
21 Avoiding situations because they frighten you
0
1
2
3
4
22 Being dependent on others
0
1
2
3
4
23 Tension and inability to relax
0
1
2
3
4
24 Anxiety, nervousness, restlessness
0
1
2
3
4
25 Spells of increased sensitivity to sound, light, or touch
0
1
2
3
4
26 Attacks of diarrhea
0
1
2
3
4
27 Worrying about your health too much
0
1
2
3
4
28 Feeling tired, weak, and exhausted easily
0
1
2
3
4
29 Headaches or pains in the neck or head
0
1
2
3
4
30 Difficulty in falling asleep
0
1
2
3
4
31 Waking in the middle of the night, or restless sleep
0
1
2
3
4
32 Unexpected waves of depression occurring with little or no provocation
0
1
2
3
4
33 Emotions and moods going up and down a lot in response to changes around you
0
1
2
3
4
34 Recurrent and persistent ideas, thoughts, impulses, or images that are intrusive, unwanted, senseless, or repugnant 35. Having to repeat the same action in a ritual, e.g., checking, washing, counting repeatedly, when it's not really necessary
0
1
2
3
4
 
Add all columns to find total score
         

 

Interpretation of Total Score

Total Score
Anxiety Severity
Under 20
Minimal anxiety
20 +
Mild anxiety
40 +
Moderate anxiety
60 +
Moderately severe anxiety
80 +
Severe anxiety


Disclaimer

The information on this page is provided for informational purposes only and does not replace in any way a formal medical or psychiatric evaluation or suggest a diagnosis. This  is  only a preliminary screening . It does not replace in any way a formal psychiatric evaluation or suggest a diagnosis. It is designed to give a preliminary idea about the presence of mild to moderate anxiety symptoms that indicate the need for an evaluation by a psychiatrist or medical practitioner. If you suspect you may be experiencing any  symptoms we would recommend you seek an evaluation by a psychiatrist or mental health professional. All therapy should begin with seeking any medical reasons for the presenting problem.


Disclaimer:
This  is  only a preliminary screening . It does not replace in any way a formal psychiatric evaluation. It is designed to give a preliminary idea about the presence of mild to moderate anxiety symptoms that indicate the need for an evaluation by a psychiatrist or medical practitioner.

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