Overcome Anxiety Clinic Questionnaire
This form does not collect email addresses and will be submitted anonymously unless you decide to include your name. All of these questions are optional. We use the information to try our best to customize our program to fulfill the needs of the class participants. This information is confidential and will only be viewed by the facilitator.
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Name
Pronoun
What brings you to our Overcome! Clinic? Please describe how you feel and/or act that is troublesome for you (we’ll call these “troublesome symptoms” for the remainder of the questionnaire).
How long have you noticed the troublesome symptoms you described above?
Have you ever experienced a panic attack?
Clear selection
If yes, how often and when was the last one?
Do you feel that anxiety is present in your everyday life?
Clear selection
Do you experience the following troublesome sypmtoms? Please check all that apply:
If you want to add any other symptoms that you want to address in this clinic (if possible), please write below:
Have you tried a lot of different things to resolve the troublesome symptoms?
Clear selection
If yes, please list what you have tried in the past:
Do you believe in your ability to self-heal?
Clear selection
Can you imagine what your life will be like when you conquer the troublesome symptoms?
Clear selection
Who (person or group) feels like a support network for you (friends, partner, church group and/or family)?
How often do you exercise? What form of exercise and how often?
How did you hear about our program?
If you are here for medication step-down support (to manage withdrawal symptoms) please answer the following:
***Do not stop taking any medications without the consent and supervision of your healthcare provider. If you are here for step-down support, you must be under the supervision of a prescribing healthcare professional***
Are you currently taking medications?
Clear selection
If yes, how long have you been taking them?
Please describe the symptoms you experience that you believe are due to your step-down program:
What are your expectations from this program?
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