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You may experience only one of the five symptoms listed above or a combination of a few or many. Keep in mind that some form of anxiety is normal in life, but it's when anxiety limits or interferes with your ability to lead a "normal" life that there's reason for concern. When this happens, it is time for CHAANGE.
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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To start the process of liberating yourself from anxiety check out our Chaange Anxiety Treatment Program for adults and our Life Skills program for children.
or email info@treatmentanxiety.com
Please click the link for a more detailed Evaluation Form. |
