Assessment of Anxiety Disorders
Please fill the Form below. Answer all the Questions. Dont think too much. Fill it With The Answer that comes first to your mind. Your response will be kept confidential. It will be used only for treatment and research purpose. Copyright © 2021 psyclinic
Name/Nick name
Email
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Date of filling the form
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Give a short description of your problem
Do you use any substances like alcohol, cannabis ,nicotine etc. If yes specify the type of substance, quantity of intake, how often etc.
Please tick the appropriate column. Dont think too much on every question. Answer the first answer that comes to your mind.
Rows
Never
Rarely
Some times
Most times
Always
Feel nervous and anxious for simple reasons
Unable to control worrying
Keep worrying the whole day
Unable to relax and take rest properly
Gets annoyed and irritated soon
Difficulty in concentration and poor memory
Feels dry mouth, headache, sweating too much when anxious
Feels tremor of hands while anxious
Feels abdominal pain, burning sensation, vomiting sensation when anxious
Feels rapid respiration, shortness of breath, choking when anxious
Feels pain in chest, palpitation when anxious
Trouble falling to sleep
Keeps thinking about the things you have done and doubts whether it was appropriate or not.
Feeling excessive fear towards certain persons, places or things
Fears that something bad may happen
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