Name: Date: | ||||
For each item below, please place a check mark (v) in the column which best describes how often you felt or behaved this way during the past several days | ||||
Bring the form with you to the office for scoring and assessment during your office visit | ||||
Place check mark (√) in correct column | A little of the time | Some of the time | Goof part of the time | Most of the time |
1. I feel more nervous and anxious than usual | 1. | 2. | 3. | 4. |
2. I feel afraid for no reason at all | 1. | 2. | 3. | 4. |
3. I get upset easily or feel panicky | 1. | 2. | 3. | 4. |
4. I feel like I am falling apart and going to pieces | 1. | 2. | 3. | 4. |
5. I feel that everything is all right and nothing bad will happen | 1. | 2. | 3. | 4. |
6. My arms and legs shake and tremble | 1. | 2. | 3. | 4. |
7. I am bothered by headaches neck, and back pain | 1. | 2. | 3. | 4. |
8. I feel weak and get tired easily | 1. | 2. | 3. | 4. |
9. I feel calm and can sit still easily | 1. | 2. | 3. | 4. |
10. I can feel my heart beating fast | 1. | 2. | 3. | 4. |
11. I am bothered by dizzy spells | 1. | 2. | 3. | 4. |
12. I have fainting spells or feel like it | 1. | 2. | 3. | 4. |
13. I can breathe in and out easily | 1. | 2. | 3. | 4. |
14. I get feelings of numbness and tingling in my fingers and toes | 1. | 2. | 3. | 4. |
15. I am bothered by stomach aches or indigestions | 1. | 2. | 3. | 4. |
16. I have to empty my bladder often | 1. | 2. | 3. | 4. |
17. My hands are usually dry and warm | 1. | 2. | 3. | 4. |
18. My face gets hot and blushes | 1. | 2. | 3. | 4. |
19. I fall asleep easily and get a good night’s rest | 1. | 2. | 3. | 4. |
20. I have nightmares | 1. | 2. | 3. | 4. |