Internet Screening
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INSTRUCTIONS

 
We appreciate your interest in our anxiety studies at the Laboratory for the Study of Anxiety Disorders at the University of Texas. We are currently conducting research examining several brief psychological interventions for reducing anxiety problems. In order to be eligible, you must be: a) 18 or older, b) have internet access, c) able to provide transportation to UT campus, and d) pass a screening interview.

To apply, please complete the required prescreening survey. This survey asks about your anxiety problems and should only take a few minutes to complete. This is a first step in the screening process. Upon completion of the survey, the research staff will contact you to schedule a face to face screening interview. The face to face screening interview will be the last required step in determining your eligibility for our anxiety studies.
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1. Last name?

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2. First name?

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3. What is the best phone number to reach you?

4. What is the best email to send you study information?

5. Gender

6. Which of the following ethnic groups do you belong?

(IT IS OK TO CLICK MORE THAN ONE GROUP)

7. What is your date of birth (MONTH/DAY/YEAR) Ex: 03/24/1974

8. Participation in the anxiety studies require that you be able to provide transportation to and from the research lab at UT. Would you be able to meet this requirement?

9. Participation in the anxiety studies require that you are able to read and write in English. Are you able to meet this requirement?

10. Participation in the anxiety studies require that you have access to the internet and an email address. Would you be able to meet this requirement?

11. Do you currently have any of the following medical problems?

12. Have you EVER taken medication for an emotional problem?

13. When did you last take the medication?

14. Has your dose changed over the last 4 weeks?

15. Are you willing to stay on the same dose during your participation in the study?

16. Have you ever received individual or group counseling for emotional problems?

17. Listed below are certain major types of anxiety problems. For each type, please indicate whether you have experienced this either in the past or currently.

 PastCurrentNone
Intense fear of public speaking
Strong fear of being judged negatively by others including strangers
High anxiety or uncontrollable worries about a number of things including your health, finances, job, school, or relationships
Anxiety connected to UNWANTED senseless thoughts or images that seem to come into your mind (for example being contaminated by germs, harming others, being responsible for something bad happening)
Senseless actions that you feel compelled to do over and over such as washing your hands, checking , or counting
Anxiety connected to a traumatic event
Intense fear of enclosed places
Intense fear and avoidance of spiders or snakes
Panic attacks or a fear of having a panic attack
Anxiety about having a serious medical condition even though you have been told by doctors that your health is fine
None of the above
Other

18. Which of the anxiety problem that were just reviewed seem to be causing you the most interference or distress in your life?

19. Next, it asks you about a number of specific anxiety symptoms. For each symptom, please indicate how much the symptom has bothered you during the past 7 days.

 Not at allMildly (it did not bother me much)Moderately (it was very unpleasant)Severely (I could barely stand it)
Numbness or tingling
Feeing hot (not due to heat)
Wobbliness in legs
Unable to relax
Fear of the worst happening
Dizzy or lightheaded
Heart pounding or racing
Unsteady
Terrified
Nervous
Feelings of choking
Hands trembling
Shaky
Fear of losing Control
Difficulty breathing
Fear of dying
Scared
Indigestion or stomach discomfort
Faint
Face flushed
Sweating (not due to heat)

20. Please indicate how much you agree with each item. If any items concern something you have never experienced, please answer based on how you think you might feel if you had such an experience.

 Very LittleA LitteSomeMuchVery Much
1. It is important for me not to appear nervous.
2. When I cannot keep my mind on a task, I worry that I might be going crazy.
3. It scares me when my heart beats rapidly.
4. When my stomach is upset, I worry that I might be seriously ill.
5. It scares me when I am unable to keep my mind on a task.
6. When I tremble in the presence of others, I fear what people might think of me.
7. When my chest feels tight, I get scared that I won’t be able to breathe properly.
8. When I feel pain in my chest, I worry that I am going to have a heart attack.
9. I worry that other people will notice my anxiety.
10. When I feel “spacey” or spaced out I worry that I may be mentally ill.
11. It scares me when I blush in front of people.
12. When I notice my heart skipping a beat, I worry that there is something seriously wrong with me.
13. When I begin to sweat in a social situation, I fear people will think negatively of me.
14. When my thoughts seem to speed up, I worry that I might be going crazy.
15. When my throat feels tight, I worry that I could choke to death.
16. When I have trouble thinking clearly, I worry that there is something wrong with me.
17. I think it would be horrible for me to faint in public.
18. When my mind goes blank, I worry there is something terribly wrong with me.

OK you're done! The next step is that Dr. Telch and his staff will review the information you provided today. Someone will be calling you back to discuss the next step and provide you more information about our anxiety treatment study. If you do not here back from someone with the next week, please call our lab at 404-9118. Thanks again and you will be contacted soon.

21. Best days and times to call you back