Instructions

Everyone experiences some amount of anxiety in their daily lives.

We want to know specifically what things make you anxious, and how often you've been feeling this way. 

Please rate the approximate frequency of the following experiences over the past 6 months, by selecting one of the following:
•    Never: I have not had this experience in the past 6 months.

•    Monthly: I have this experience about once per month.

•    Weekly: I have this experience at least once per week.

•    Daily: I have this experience every day.

•    Hourly: This experience occurs throughout the day.

In the past six (6) months, I have:

1. Had an anxiety or panic attack*.
*A sudden rush of intense fear, anxiety, or physical discomfort that may occur unexpectedly, or out of the blue.
2. Worried about having an anxiety or panic attack in the future.
3. Had a strong fear or aversion to certain places or circumstances*.
*Such as open spaces, small or crowded places, public transportation, standing in line, or being away from home.
4. Felt very nervous or uncomfortable around others who may be evaluating me, or of doing or saying something embarrassing*.
*Such as while eating, having a conversation, meeting new people, public speaking, or using the bathroom.
5. Felt very fearful or anxious in the presence of certain objects or situations.
*Such as animals, insects, heights, storms, airplanes, elevators, confined spaces, water, blood, or injections or other medical procedures.
6. Had excessive worries that were difficult to control, about a variety future events and activities.
7. Experienced the following physical states while I was worrying (Check all that apply):
8. Been re-experiencing a past traumatic event, which makes me distressed or reactive, and I try to avoid seeing, hearing, or thinking about things that remind me of it.
9. Been anxious or distressed about intrusive* or inappropriate thoughts or images, that I try to neutralize with some other thought or action.
*That is, difficult to ignore or suppress.
10. Felt driven to perform excessive, repetitive behaviors or mental acts, according to certain rules, in response to certain thoughts, or to prevent a dreaded event.
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