Anxiety Symptom Questionnaire
Completion of the following self-report scale will provide you information
as to the type of anxiety you experience as well as to what extent. Print and complete this scale, and keep for your records.
It will also provide helpful diagnostic information for your physician or therapist.
Section A:
1. Have you ever had a panic attack?
Yes___ No___
2. If yes, have you had at least one such attack in the last month?
Yes___ No___
3. If you had an attack in the last month, did you worry about having another?
Or did you worry about the implications of the attack for your physical or mental health?
Yes___ No___
4. In your worst experience with anxiety, which of the following symptoms did
you experience?
___ shortness of breath or smothering sensation
___ dizziness or unsteady feeling
___ heart palpitations or rapid heartbeat
___ trembling or shaking
___ sweating
___ choking
___ nausea or abdominal distress
___ feelings of being detached or out of touch with your body
___ numbness or tingling sensations
___ flushes or chills
___ chest pain or discomfort
___ fear of dying
___ fear of going crazy or doing something out of control
Section B:
5. Does fear of having panic attacks cause you to avoid going into certain
situations?
Yes ___ No ___
6. If yes, which of the following situations do you avoid?
___ going far away from home
___ shopping in a grocery store
___ standing in a checkout line
___ going to department stores
___ going to shopping malls
___ driving on freeways
___ driving on surface streets far from home
___ driving anywhere by yourself
___ using public transportation: buses, trains, planes
___ going over bridges
___ going through tunnels
___ riding in elevators
___ being in high places
___ going to a dentist's or doctor's office
___ sitting in barber's or hairstylist's chair
___ eating in restaurants
___ going to work
___ being too far from a safe person or safe place
___ being alone outside the home
___ going outside your home
Section C:
7. Do you avoid certain situations because you are afraid of being embarassed
or negatively evaluated by others, or where embarassement could lead to panic?
Yes ___ No ___
8. If yes, which of the following situations do you avoid because of
a fear of embarrassment or humiliation?
___ sitting in any kind of group (for example: at work, school classroom,
social organizations, self-help groups)
___ giving a talk or presentation before a small group of people
___ giving a talk or presentation before a large group of people
___ parties or social functions
___ using public restrooms
___ eating in front of others
___ writing or signing your name in the presence of others
___ dating
___ any situation where you might say something foolish
Section D:
10. Do you feel quite anxious much of the time?
Yes
___ No ___
11. Have you been quite anxious for at least the last six months? Yes
___ No ___
12. If yes, which of the following symptoms have you been experiencing?
___ restlessness or feeling keyed up or on edge
___ being easily fatigued
___ difficulty concentrating or mind going blank
___ irritability
___ muscle tension
___ sleep disturbance (difficulty falling or staying asleep)
Section E:
13. Do you have recurring, intrusive thoughts such as hurting or harming
a close relative, being contaminated with dirt or a toxic substance, fearing you forgot to lock your door or turn off an appliance
(recognizing these thoughts are irrational)?
Yes
___ No ___
14. Do you perform ritualistic actions such as washing your hands, checking
or counting to relieve anxiety over irrational fears that enter your mind?
Yes ___ No ___
Section F:
15. Have you ever experienced a traumatic event in which you felt intense
fear because you either experienced or witnessed an actual death or threat of death or serious injury? Yes___No___
16. Since this event have you experienced:
___ intrusive and distressing recollections of the event
___ recurrent distressing dreams of the event
___ feeling the event was recurring (reliving it, illusions of it, or
flashbacks)
___ emotional distress over reminders of the event
___ physical distress over reminders of the event
17. Since the event have you experienced:
___ attempts to avoid thoughts, feelings or discussion of the event
___ attempts to avoid people, places or activities that remind you of
the event
___ difficulty remembering an important part of the event
___ decrease in interest and involvement in important activities
___ feeling detached from others
___ limited emotions
___ expecting to have a limited future
18. Since the event have you experienced:
___ difficulty falling or staying asleep
___ irritability or temper outbursts
___ difficulty concentrating
___ hypervigilence
___ exaggerated startle response
Scoring:
Section A tests for the presence of Panic Disorder (PD).
If you answer yes to questions 1 and 2 only, you do not necessarily have Panic Disorder. Studies have indicated that
7% to 34% of the general population has experienced an occasional panic attack. If you answer yes to question 3, you are experiencing
an important feature of PD, that is, the fear of having another attack or the fear of fear cycle. That fear can help
perpetuate the development of further attacks and exacerbate the problem. If this fear of fear is causing recurrent attacks,
you have Panic Disorder.
How do you know if the anxiety symptoms you experienced
constitute a panic attack? If you experienced 4 or more of the symptoms in question 4 within a 10 minute period, you had a
panic attack.
Section B tests for the presence of Agoraphobia: the
fear of being in places or situations from which escape is difficult, or the fear of help being unavailable if you experience
a panic attack. If you check yes to question 5, you may have agoraphobia. The more situations checked in question 6 suggest
a greater degree of agoraphobia.
Section C tests for Social Phobia. If you check
yes to question 7, you likely have Social Phobia. The more situations checked in question 8 suggest a greater degree of Social
Phobia.
Section D tests for Generalized Anxiety Disorder (GAD).
If you answer yes to questions 10 and 11, you likely have GAD. If you also check 3 or more of the items in question 12, you
do have GAD.
Section E tests for Obsessive-Compulsive Disorder (OCD).
If you answer yes to question 13, you are experiencing obsessions. If you answer yes to question 14, you are experiencing
compulsions. Answering yes to either or both constitutes OCD.
Section F tests for Posttraumatic Stress Disorder (PTSD).
If you answer yes to question 15 and check one or more in 16, and check 3 or more in 17, and check
2 or more in 18, and these have lasted at least one month, you have PTSD.
