Anxiety Disorder Self-Assessment Questionnaire

Answer the following questions about your anxiety symptoms. If you check more than one question in a block, one of our free anxiety self-help programs may help you.

BLOCK 1

_____ Do you experience sudden episodes of intense and overwhelming fear that seem to come on for no apparent reason?

_____ During these episodes, do you experience symptoms similar to the following? racing heart, chest pain, difficulty breathing, choking sensation, lightheadedness, tingling or numbness?

_____ During the episodes do you worry about something terrible happening to you, such as embarrassing yourself, having a heart attack or dying?

_____ Do you worry about having additional episodes?

BLOCK 2

_____ Do you worry about a number of events or activities (such as work or school performance)?

_____ Is it difficult to control the worry.

_____ Do you also have two or more of these symptoms?

• feeling restless or on edge
• being easily fatigued
• having difficulty concentrating
• feeling irritable
• muscle tension
• having difficulty falling or staying asleep, or restless unsatisfying sleep

BLOCK 3

_____ Have you experienced or witnessed a frightening, traumatic event, either recently or in the past?

_____ Do you continue to have distressing recollections or dreams of the event?

_____ Do you become anxious when you face anything that reminds you of that traumatic event?

_____ Do you try to avoid those reminders?

_____ Do you have any of the following symptoms: difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, feeling "on guard", easily startled?

BLOCK 4

_____ Do you have recurring thoughts or images (other than the worries of everyday life) that feel intrusive and make you anxious?

_____ On occasion, do you know that these thoughts or images are unreasonable or excessive?

_____ Do you want these thoughts or images to stop, but can't seem to control them?

_____ Do you engage in any repetitive behaviors (like hand washing, ordering, or checking) or mental acts (like praying, counting, or repeating words silently) in order to end these intrusive thoughts or images.

BLOCK 5

_____ Are you afraid of one or more social or performance situations?

• speaking up
• taking a test
• eating, writing or working in public
• being the center of attention
• asking someone for a date

_____ Do you get anxious and worried if you try to participate in those situations?

_____ Do you avoid these situations when possible?

BLOCK 6

_____ Are you afraid on one specific object or situation, such as heights, storms, water, animals, elevators, closed-in spaces, receiving an injection, or seeing blood (excluding social situations)?

_____ Do you get anxious and worried if you try to participate in those situations?

_____ Do you avoid these situations when possible?

BLOCK 7

_____ Are you afraid of flying or a commercial airliner?

_____ Do you get anxious and worried if you fly?

_____ Do you avoid flying when possible?

BLOCK 8

_____ Are you interesting in learning more about how medications might help you manage your symptoms?

_____ Or are you currently taking a medication and wish to learn more about its benefits?

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