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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