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Self-Assessment Questionnaire

Answer the following questions about your symptoms. If you check more than one question in a block, one of our free self-help programs may help you.  See the bottom of the page for the program that matches each block.

BLOCK 1
Do you experience sudden episodes of intense and overwhelming fear that seem to come on for no apparent reason?
During these episodes, do you experience symptoms similar to the following? racing heart, chest pain, difficulty breathing, choking sensation, lightheadedness, tingling or numbness?
During the episodes do you worry about something terrible happening to you, such as embarrassing yourself, having a heart attack or dying?
Do you worry about having additional episodes?
BLOCK 2
Do you worry about a number of events or activities (such as work or school performance)? 
Is it difficult to control the worry.
Do you also have two or more of these symptoms?
  • feeling restless or on edge
  • being easily fatigued
  • having difficulty concentrating
  • feeling irritable
  • muscle tension
  • having difficulty falling or staying asleep, or restless unsatisfying sleep
BLOCK 3
Have you experienced or witnessed a frightening, traumatic event, either recently or in the past?
Do you continue to have distressing recollections or dreams of the event?
Do you become anxious when you face anything that reminds you of that traumatic event?
Do you try to avoid those reminders?
Do you have any of the following symptoms: difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, feeling "on guard", easily startled?
BLOCK 4
Do you have recurring thoughts or images (other than the worries of everyday life) that feel intrusive and make you anxious?
On occasion, do you know that these thoughts or images are unreasonable or excessive?
Do you want these thoughts or images to stop, but can't seem to control them?
Do you engage in any repetitive behaviors (like hand washing, ordering, or checking) or mental acts (like praying, counting, or repeating words silently) in order to end these intrusive thoughts or images.
BLOCK 5
Are you afraid of one or more social or performance situations?
     -speaking up
     -taking a test
     -eating, writing or working in public
     -being the center of attention
     -asking someone for a date 
Do you get anxious and worried if you try to participate in those situations?
Do you avoid these situations when possible?
BLOCK 6
Are you afraid on one specific object or situation, such as heights, storms, water, animals, elevators, closed-in spaces, receiving an injection, or seeing blood (excluding social situations)?
Do you get anxious and worried if you try to participate in those situations?
Do you avoid these situations when possible?
BLOCK 7
Are you afraid of flying or a commercial airliner?
Do you get anxious and worried if you fly?
Do you avoid flying when possible?
BLOCK 8
Are you interesting in learning more about how medications might help you manage your symptoms?
Or are you currently taking a medication and wish to learn more about its benefits?

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