Anxiety Symptom Rating Scale
Please rate how much each of the following has bothered you over the past week, including today.
Numbness or tingling
*
Please Select
0 – Not at all
1 – Mildly, but it didn’t bother me much
2 – Moderately – it wasn’t pleasant at times
3 – Severely – it bothered me a lot
Feeling hot
*
Please Select
0 – Not at all
1 – Mildly, but it didn’t bother me much
2 – Moderately – it wasn’t pleasant at times
3 – Severely – it bothered me a lot
Wobbliness in legs
*
Please Select
0 – Not at all
1 – Mildly, but it didn’t bother me much
2 – Moderately – it wasn’t pleasant at times
3 – Severely – it bothered me a lot
Unable to relax
*
Please Select
0 – Not at all
1 – Mildly, but it didn’t bother me much
2 – Moderately – it wasn’t pleasant at times
3 – Severely – it bothered me a lot
Fear of worst happening
*
Please Select
0 – Not at all
1 – Mildly, but it didn’t bother me much
2 – Moderately – it wasn’t pleasant at times
3 – Severely – it bothered me a lot
Dizzy or lightheaded
*
Please Select
0 – Not at all
1 – Mildly, but it didn’t bother me much
2 – Moderately – it wasn’t pleasant at times
3 – Severely – it bothered me a lot
Heart pounding / racing
*
Please Select
0 – Not at all
1 – Mildly, but it didn’t bother me much
2 – Moderately – it wasn’t pleasant at times
3 – Severely – it bothered me a lot
Unsteady
*
Please Select
0 – Not at all
1 – Mildly, but it didn’t bother me much
2 – Moderately – it wasn’t pleasant at times
3 – Severely – it bothered me a lot
Terrified or afraid
*
Please Select
0 – Not at all
1 – Mildly, but it didn’t bother me much
2 – Moderately – it wasn’t pleasant at times
3 – Severely – it bothered me a lot
Nervous
*
Please Select
0 – Not at all
1 – Mildly, but it didn’t bother me much
2 – Moderately – it wasn’t pleasant at times
3 – Severely – it bothered me a lot
Feeling of choking
*
Please Select
0 – Not at all
1 – Mildly, but it didn’t bother me much
2 – Moderately – it wasn’t pleasant at times
3 – Severely – it bothered me a lot
Hands trembling
*
Please Select
0 – Not at all
1 – Mildly, but it didn’t bother me much
2 – Moderately – it wasn’t pleasant at times
3 – Severely – it bothered me a lot
Shaky / unsteady
*
Please Select
0 – Not at all
1 – Mildly, but it didn’t bother me much
2 – Moderately – it wasn’t pleasant at times
3 – Severely – it bothered me a lot
Fear of losing control
*
Please Select
0 – Not at all
1 – Mildly, but it didn’t bother me much
2 – Moderately – it wasn’t pleasant at times
3 – Severely – it bothered me a lot
Difficulty in breathing
*
Please Select
0 – Not at all
1 – Mildly, but it didn’t bother me much
2 – Moderately – it wasn’t pleasant at times
3 – Severely – it bothered me a lot
Fear of dying
*
Please Select
0 – Not at all
1 – Mildly, but it didn’t bother me much
2 – Moderately – it wasn’t pleasant at times
3 – Severely – it bothered me a lot
Scared
*
Please Select
0 – Not at all
1 – Mildly, but it didn’t bother me much
2 – Moderately – it wasn’t pleasant at times
3 – Severely – it bothered me a lot
Indigestion
*
Please Select
0 – Not at all
1 – Mildly, but it didn’t bother me much
2 – Moderately – it wasn’t pleasant at times
3 – Severely – it bothered me a lot
Faint / lightheaded
*
Please Select
0 – Not at all
1 – Mildly, but it didn’t bother me much
2 – Moderately – it wasn’t pleasant at times
3 – Severely – it bothered me a lot
Face flushed
*
Please Select
0 – Not at all
1 – Mildly, but it didn’t bother me much
2 – Moderately – it wasn’t pleasant at times
3 – Severely – it bothered me a lot
Hot / cold sweats
*
Please Select
0 – Not at all
1 – Mildly, but it didn’t bother me much
2 – Moderately – it wasn’t pleasant at times
3 – Severely – it bothered me a lot
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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