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Anxiety Self-Rating Scale
INSTRUCTIONS: This scale is designed for your personal use. There are no right or wrong
answers. Usually your first response is the best. Please print these pages out for your personal
reference. If you like, there is also a Depression Self-Rating Scale.
For each item decide if it
NEVER applies to you (mark 0)
SOMETIMES applies to you (mark 1)
HALF THE TIME applies to you (mark 2)
FREQUENTLY applies to you (mark 3)
ALWAYS applies to you (mark 4)
When you are finished add up your totals in all 5 columns to get your TOTAL SCORE.
Make sure you base your answers on how you actually behave in your daily life, not on how you would like to be
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Full Name
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Your answer
Phone Number
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Your answer
This scale is designed for your personal use. There are no right or wrong answers. Usually your first response is the best. Please print these pages out for your personal use. You may also bring this assessment with you to your appointment and discuss the findings during your visit.
I feel tense, nervous, restless, or agitated
Never
0
1
2
3
4
Always
Clear selection
I feel afraid for no apparent reason
Never
0
1
2
3
4
Always
Clear selection
I worry about bad things that might happen to me or those I care about
Never
0
1
2
3
4
Always
Clear selection
I have difficulty falling asleep, staying asleep or waking up early
Never
0
1
2
3
4
Always
Clear selection
I have difficulty eating too much, too little or digesting my food
Never
0
1
2
3
4
Always
Clear selection
I wish I knew a way to make myself more relaxed
Never
0
1
2
3
4
Always
Clear selection
I have difficulty with my concentration, memory or thinking
Never
0
1
2
3
4
Always
Clear selection
I would say I am anxious much of the time
Never
0
1
2
3
4
Always
Clear selection
From time to time I have experienced a racing heartbeat, cold hands or feet, dry mouth, sweating, tight muscles, difficulty breathing, numbness, frequent urination, or hot/cold flashes
Never
0
1
2
3
4
Always
Clear selection
I wish I could be as relaxed with myself as others seem to be
Never
0
1
2
3
4
Always
Clear selection
SCORING: Total the number of points in each of the columns. Add all columns together to get yourTOTAL SCORE
MINIMAL ANXIETY - 0 to 8 point
MILD ANXIETY - 8 to 16 points
MODERATE ANXIETY - 17 to 24 points
HIGH ANXIETY (Warning Level) - 25 to 32 points
EXTREME ANXIETY (Warning Level) - 33 to 40 points
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