Yes | No Excessive worry, occurring more days than not, for a least six months?
Yes | No Unreasonable worry about a number of events or activities, such as work or school and/or health?
Yes | No The inability to control the worry?
Yes | No Are you bothered by a least three of the following?
Yes | No Restlessness, feeling keyed-up or on edge?
Yes | No Being easily tired?
Yes | No Problems concentrating?
Yes | No Irritability?
Yes | No Muscle tension?
Yes | No Trouble falling asleep or staying asleep, or restless and unsatisfying sleep?
Yes | No Does your anxiety interfere with your daily life?
Having more than one illness at the same time can make it difficult to diagnose and treat the different conditions. Illnesses that sometimes complicate anxiety disorders include depression and substance abuse. With this in mind, please take a minute to answer the following questions:
Yes | No Have you experienced changes in sleeping or eating habits?
More days than not, do you feel:
Yes | No Sad or depressed?
Yes | No Disinterested in life?
Yes | No Worthless or guilty?
During the last year, has the use of alcohol or drugs:
Yes | No Resulted in your failure to fulfill responsibilities with work, school, or family?
Yes | No Placed you in a dangerous situation, such as driving a car under the influence?
Yes | No Gotten you arrested?
Yes | No Continued despite causing problems for you and/or your loved ones?
Reproduced with permission of the Anxiety Disorder Association of America