Anxiety Questionnaire
Anxiety Questionnaire
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Email *
Full Name *
Phone Number *
How long have you suffered from anxiety? *
What was happening in your life in the 3 months prior to its onset? *
If this was something specific, had you experienced a similar situation before that? *
Have you experienced any major life changes in the last 2 years? *
How do you usually cope with anxiety?
Are you currently taking medication for anxiety? If so, how long have you been taking this? Does it help? *
Does your anxiety interfere with your participation in everyday activities? *
Explain how your anxiety interfere with your participation in everyday activities *
How long does a typical anxiety attack last? *
How often do you experience symptoms of anxiety?   *
When did you last experience anxiety? *
What do you think caused this? *
How did you cope with it? *
Does anxiety affect you more in company or alone? *
Please tick any of the symptoms that you experience below: *
Required
Do you have suicidal thoughts? If so, have you ever attempted to act on these? *
Do you have a caring support structure?
Who would you normally turn to for help with your anxiety? *
Have you ever sought help from? *
Required
Have you previously discussed your present anxiety state with a medical adviser? If so, are you receiving treatment (other than medication) for this? *
Do you tend to bottle up your problems? *
Do you often worry about things that others consider unreasonable? *
Apart from the anxiety, do you have any specific health problems? *
Are you concerned about the health or well-being of a family member or close friend? *
Are you solely responsible for the care of an elderly relative, disabled family member or child?
Have other members of your close family suffered from anxiety? If so, who and how does this affect them?
Relationship to your Mother *
Required
Relationship to your Father *
Required
Relationship to your Children *
Required
Relationship to your Work colleagues *
Required
Relationship to your Superior *
Required
Relationship to your Neighbors *
Required
Relationship to your Friends *
Required
Do you have financial worries? *
Is your life generally well-organized? *
Are there any situations which you have been/are currently avoiding tackling? *
Do you have any specific needs that are not being met? *
Do you feel under pressure?  If so, please elaborate: *
On a scale of 1 to 10, (ten being the highest) how happy are you with your life at present? *
What specific things do you think would need to happen for you to feel better? *
Out of this list, which do you feel that you have control over? *
What, if anything, do you feel you would need to do in order to effect this change? *
Please list any obstacles that you believe are preventing you from effecting this change: *
If anxiety was not a problem for you, what would you like to see yourself doing in one year’s time? *
If anxiety was not a problem for you, what would you like to see yourself doing in five year’s time? *
If anxiety was not a problem for you, what would you like to see yourself doing in ten year’s time? *
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