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Anxiety Treatment Evaluation Form
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1.
Approximately how many times per week do you feel anxious (have
anxiety symptoms)? __________ times.
2.
Indicate the approximate number of hours on a typical day you
are actively troubled by anxiety (either thinking about it,
worrying, frightened, etc.) Please indicate a specific number
even if it is just an estimate. ___________ hours per day.
3. So that
we can have a sense of where you might need the most help and a
way to measure progress, please check the boxes below that
apply to you. Please be sure to indicate the degree to which
your happiness and/or productivity are impeded by marking
the one to ten scales placed after each item you have checked (0
being least and 10 being most).
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 I
have had one or more experiences of
suddenly feeling very fearful with
symptoms such as shortness of breath,
palpitations, chest pain or discomfort,
choking or smothering sensations, with
fear of going crazy, losing control, a
sense of impending doom, or perhaps even
dying. |
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To keep from feeling afraid, perhaps going out
of control, I tend to avoid certain
situations such as: (if applies, please
list)____________________,
____________________,
____________________, &
____________________ . |
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I experience irrational fear and discomfort
only when I am anticipating or actually
faced with a specific item or situation
(e.g. flying, spiders, heights, etc.)
List up to four of the most debilitating
things:
___________________,
___________________,
___________________,
___________________. |
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I have a strong unreasonable fear of one or
more social or performance situations
when I meet new people and/or might be
judged. I fear acting in a way that
might be humiliating or embarrassing to
me. |
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I tend to worry excessively and become very
distressed about the same negative
thoughts, images or impulses, and have
trouble dismissing them. At least some
relief is gained when I perform certain
behaviors or rituals to feel less tense
and troubled. |
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Ever since I suffered a traumatic/greatly
stressful event, I've been troubled with
some of the following (Please
underline): Disturbing memories,
avoidances, sleep problems,
irritability, trouble concentrating,
jumpiness, flashbacks, loss of interest
in the future, feeling "on guard",
unable to function some days, depressed,
guilty. |
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I am generally uncomfortable or anxious much
of the time, even though I don't worry
about or fear having a panic attack or
being embarrassed. I am unable to
control the sense of apprehension I feel
about a number of things. |
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4. List
below medications you are currently
taking and the usual dosage per day: |
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Medications |
Dosage |
How Often |
Why Prescribed |
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If you
are currently taking medications for
your anxiety condition, please indicate
how helpful it (they) has (have) been in
proving relief from your distress.
(Circle a number) |
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No
Relief
at all. |
Complete
Relief |
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5. How
would you rate the present state of your
anxiety symptoms? (Circle a number) |
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No
Anxiety
Present |
Slightly
Disturbing/
Not Really Disturbing |
Definitely
Disturbing/
Disabling |
Markedly
Disturbing/
Disabling |
Very
Seriously Disturbing/
Disabling |
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6.
Please indicate how much control of your
life you now feel. (Circle a number) |
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No
Control |
Complete
Control |
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7.
Circle the number below which best
describes the overall level of
happiness, everything considered, of
your present marriage, or primary
relationship. (If you are not currently
married or in a relationship, just skip
this question) The middle point, happy,
represents the degree of happiness which
most people get from marriage or a
relationship, and the scale gradually
ranges on one side to those few who are
very unhappy, and on the other side, to
those few who experience extreme joy or
happiness in marriage, or in a primary
relationship. |
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Very
Unhappy |
Happy |
Perfectly Happy |
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8. In
general, how satisfying do you find the
way you're spending your life these
days? Which of the following would you
call it? (Circle one) |
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Not At
All
Satisfying |
Not Very
Satisfying |
Pretty
Satisfying |
Completely
Satisfying |
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9. Please indicate
how depressed you feel at this time in your life.
(Circle one)
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Not At All
Depressed. |
Extremely
Depressed |
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10. Please give a
brief description on your anxiety condition now.
Depression is also of interest. |
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11. Highest level of
schooling completed? ___________________
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12. What is your
occupation? __________________________ |
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13. Do you have
children living at home? _____ Yes _____ No
If yes, please list their ages:
_____________________________ |
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14. Please tell us
how you heard of the CHAANGE Program, and what
convinced you to enroll.
What was it in the free information kit and/or
web page that helped?
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15. Have you ever
seen a psychologist, psychiatrist or other
professional or counselor for help for your anxiety
condition?
Yes _____ No _____
Email: info@treatmentanxiety.com
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