| CLINICIAN | ________________________________________________ | DATE____________ | |||
| PATIENT | ________________________________________________ |
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| INFORMANT IF NEEDED (& RELATIONSHIP)____________________________________________ | |||||
| Screening question—ask for clarification if necessary, also for deciding on dysfunction | Present to a dysfunctional level? | ||||
| 1) | Semi-paralyzing anxiety: (a) Do you often find yourself becoming very, very anxious and cannot easily calm yourself down? | Yes | No | ||
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| (b) Have you ever been diagnosed with—or do you suffer from—serious depression? (NO to both: EXIT) | Yes (GO TO DEP-6) | No
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| 2) | Panic disorder: Have you ever had what is called a panic attack—your heart races, you get all dizzy, and think you’re having a heart attack and are going to die? IF YES: Do you get scared about having another panic attack? | Yes | No | ||
| 3) | PTSD: Do you ever have recurring vivid flashbacks or nightmares about something horrible or upsetting that you’ve seen or been through? | Yes | No | ||
| 4) | OCD: Would you describe yourself as an overly obsessive-compulsive person —Is there something you cannot resist doing over and over so that you get very anxious until it’s done? | Yes (GO TO 8) | No | ||
| 5) | Body dysmorphic disorder: Are you uncomfortable with your physical appearance? IF YES: What causes you the most worry? WRITE IN: _____________________________ | Yes (GO TO 8) | No | ||
| 6) | GAD: Getting back to that uncontrollable anxiety that you mentioned at the start—Are there many things that you constantly worry about rather than one thing in particular? | Yes (GO TO 8) | No | ||
| 7) | Social anxiety disorder: Do you find yourself avoiding social situations or public speaking situations if you possibly can? | Yes (GO TO 8) | No | ||
| 8) | Specific phobias: Do you have great fear of any of the following? TICK (√) IF YES: Flying? __ Having an accident when driving? __ Fear of heights? __ Fear of elevators or tight spaces? __ Having an injection? __ Seeing live wounds or blood? __ Sharks? Dogs? __ Snakes? __ Spiders? __ Other animals? __ IF YES, What’s the main one? WRITE IN: _______________ Other insects? __ IF YES, What’s the main one? WRITE IN: _______________ |
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