Anxiety Risk Assessment

Take this quick screening

This questionnaire gives a sense of the likelihood of having or developing an anxiety-based condition.

Do you regularly feel nervous or fearful?
Do you feel restless, edgy, or irritable a lot? Yes No
Do you feel scared or frightened in ways that don’t feel normal to you? Yes No
Do you often have a sense of dread without knowing why? Yes No
Do you have a overwhelming feeling of being uptight and tense throughout a typical day? Yes No
Do you often have episodes that feel like heart palpitations or racing heartbeat, or that involve chest tightness, hot flashes or chills, or cold, clammy hands? Yes No
Do you have difficulty concentrating? Yes No

Are you jumpy, or easily startled or alarmed?

Yes No
Do you feel self-conscious or insecure most of the time? Yes No
Do you feel overly vigilant or wary most of the time? Yes No

Do you have trouble falling or staying asleep?

Yes No
Do things that seem like they should be normal activities of life bring on a level of anxiousness that causes you to avoid them? Yes No
Have worrisome feelings caused you to stop activities that you were previously able to include in your life? Yes No
Have you ever had a spell that developed quickly in which you felt immobilized, out of breath, panicked, or out of control? Yes No

Do you feel driven or forced by yourself to do certain activities over and over again?

Yes No

Have you experienced stressful life events recently or major life challenges such as death of a loved on, divorce, loss of job, or illness?

Yes No

Do you have nagging physical symptoms that don’t seem to go away or that you don’t find a reason for (including headaches, muscle tension, dizziness, frequent urination, or nausea or other digestive complaints)? 

Yes No

The more often you answered “Yes” to the above questions, the greater your risk for developing or already having an anxiety-based condition.  If you answered “Yes” to questions above, consider discussing anxiety with one of our Women’s Center healthcare providers.

Print this page and bring it with you, filled out, to your appointment.