Anxiety Questionnaire
A Stress & Anxiety Questionnaire
Date: ______________
Following is a list of symptoms, which usually are experienced when one is stressed or anxious.
Please print this page and circle the
number from 0 to 6 which reflects the intensity of your feelings lately.
When you feel less stress and more happy, do it again.
Rapid Heartbeat: Muscle Tension: Trembling: Lump in the Throat: Chest Pains: Heavy Perspiration: Dry Mouth: Losing Weight: Gaining Weight: Feeling Tired: Shortness of Breath: Hyperventilation: Digestive Discomfort: Diarrhea: Frequent Urination: Panic Attacks: Fear of Losing Control: Irritability: Difficulty Concentrating: Sleep Disturbance: Sensitivity to Noise: Excessive Worrying: Intrusive Thoughts: | Very Much Very Much Very Much Very Much Very Much Very Much Very Much Very Much Very Much Very Much Very Much Very Much Very Much Very Much Very Much Very Much Very Much Very Much Very Much Very Much Very Much Very Much Very Much | 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 | 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 | 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 | 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 | 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 | 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 | 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 | Not At All Not At All Not At All Not At All Not At All Not At All Not At All Not At All Not At All Not At All Not At All Not At All Not At All Not At All Not At All Not At All Not At All Not At All Not At All Not At All Not At All Not At All Not At All | |||||||||
If the totals are very high, (110 Points and above), it would be adviseable to discuss this with your doctor.