Anxiety Checklist
Anxiety Checklist (Please rate on a scale from 0 to 5.)
Anxiety, Nervousness 0 1 2 3 4 5
Tension, inability to relax 0 1 2 3 4 5
Restless feelings 0 1 2 3 4 5
Worrying 0 1 2 3 4 5
Fear of crowds 0 1 2 3 4 5
Fear of being alone 0 1 2 3 4 5
Fear of social situations 0 1 2 3 4 5
Insomnia 0 1 2 3 4 5
Difficulty concentrating 0 1 2 3 4 5
Physical symptoms
Ringing ears 0 1 2 3 4 5
Hot or cold flashes 0 1 2 3 4 5
Feelings of weakness 0 1 2 3 4 5
Rapid heart rate/palpitations 0 1 2 3 4 5
Chest pain 0 1 2 3 4 5
Shortness of breath 0 1 2 3 4 5
Choking feelings 0 1 2 3 4 5
Difficulty swallowing 0 1 2 3 4 5
Abdominal pain 0 1 2 3 4 5
Loose bowels 0 1 2 3 4 5
Frequent or urgent urination 0 1 2 3 4 5
Dry mouth 0 1 2 3 4 5
Sweating 0 1 2 3 4 5
Headaches 0 1 2 3 4 5
Twitching 0 1 2 3 4 5
Grinding teeth 0 1 2 3 4 5
Other:___________________________ 0 1 2 3 4 5
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