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Anxiety Rating Test
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2023-06-08T16:25:17+00:00
Get Started by Taking the Anxiety Rating Test & Scheduling Your
Free Phone Consultation
with Charles Beeson, CHt.
Step
1
of
5
20%
Name
*
First
Last
Email
*
Cell Phone
*
Disclaimer: This form is not a diagnostic instrument and is only to be used for educational, self-help purposes, within the context of your medical treatment, and by you, if you are at least 18 years of age. Share your checklist responses and assessment with your physician or other healthcare provider. The maker and provider of this form, InstaCalm, Inc., and all sponsoring partners, disclaim any liability, loss, or risk incurred as a consequence, directly or indirectly, from the use and application of any of this material. Please take the time to fill out the below form as accurately, honestly and completely as possible. All of your responses are confidential.
Feeling nervous or tense (unable to relax)
*
Never
Rarely
Sometimes
Often
Most of the times
My life is very stressful
*
Never
Rarely
Sometimes
Often
Most of the times
I feel worried, scared or fearful
*
Never
Rarely
Sometimes
Often
Most of the times
I feel anxious
*
Never
Rarely
Sometimes
Often
Most of the times
Difficulty Sleeping
*
Never
Rarely
Sometimes
Often
Most of the times
Anxiety or Panic Attacks (Racing Heart & Rapid Breathing)
*
Never
Rarely
Sometimes
Often
Most of the times
Shaking or trembling
*
Never
Rarely
Sometimes
Often
Most of the times
Chest pain or discomfort
*
Never
Rarely
Sometimes
Often
Most of the times
Irritable or angry
*
Never
Rarely
Sometimes
Often
Most of the times
Fear of losing control
*
Never
Rarely
Sometimes
Often
Most of the times
Avoid situations, certain locations or leaving the house because of anxiety
*
Never
Rarely
Sometimes
Often
Most of the times
Racing or pounding heart
*
Never
Rarely
Sometimes
Often
Most of the times
Anxious or very nervous in social situations
*
Never
Rarely
Sometimes
Often
Most of the times
Fear of public speaking, speaking to groups or giving presentations
*
Never
Rarely
Sometimes
Often
Most of the times
Fear of flying
*
Never
Rarely
Sometimes
Often
Most of the times
Fear of closed in spaces or being trapped
*
Never
Rarely
Sometimes
Often
Most of the times
Feeling detached or not in your body
*
Never
Rarely
Sometimes
Often
Most of the times
Feeling lightheaded or faint
*
Never
Rarely
Sometimes
Often
Most of the times
I am jumpy or startle easily
*
Never
Rarely
Sometimes
Often
Most of the times
I think negative or persistent uncomfortable thoughts
*
Never
Rarely
Sometimes
Often
Most of the times
My fears and anxiety affects my family, marriage or relationships
*
Never
Rarely
Sometimes
Often
Most of the times
Fear of dying
*
Never
Rarely
Sometimes
Often
Most of the times
Abdominal pain or discomfort
*
Never
Rarely
Sometimes
Often
Most of the times
Difficulty breathing or shortness of breath
*
Never
Rarely
Sometimes
Often
Most of the times
My anxiety interferes with my job or school
*
Never
Rarely
Sometimes
Often
Most of the times
Sweating
*
Never
Rarely
Sometimes
Often
Most of the times
I use drugs or alcohol to deal with my anxiety
*
Never
Rarely
Sometimes
Often
Most of the times
feeling of choking
*
Never
Rarely
Sometimes
Often
Most of the times
Obsessive checking and rechecking things
*
Never
Rarely
Sometimes
Often
Most of the times
Feeling sad or depressed
*
Never
Rarely
Sometimes
Often
Most of the times
Chills or hot flashes
*
Never
Rarely
Sometimes
Often
Most of the times
Fear of driving or being driven in an automobile
*
Never
Rarely
Sometimes
Often
Most of the times
Gender?
*
Male
Female
What is your Age Range?
*
Below 18 (Minor/Child)
18 to 25
26 to 36
37 to 55
55 to 69
Over 70
How long have you been dealing with your anxiety?
*
Less than 3 months
3 Months to 1 year
1 to 5 years
5 to 20 years
Greater than 20 years
Have you ever been diagnosed with anxiety by a medical or mental health professional?
*
Yes
No
Are you presently receiving help with any of the following?
*
Anxiety Medication
Depression Medication
Therapy/Counseling
Physician/Psychiatrist
Self-Help Techniques
None of Above
Did you have any stressful emotional events just prior to the onset of your anxiety?
*
Yes
No
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