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Initial Anxiety and Stress Assessment -- Zung Anxiety Self-Assessment Scale
For each question below please rate from feeling on a five point scale
1.
First Name
2.
Last Name
3.
email address
4.
Have you been previously diagnosed by a physician to have Anxiety
Yes
No
5.
If the answer to question 3 was yes, what type of anxiety do you suffer from?
6.
Please list any medications you are currently taking for anxiety
7.
I feel more nervous and anxious than usual
Never
Rarely
Sometimes
Usually
Always
8.
I feel afraid for no reason at all
Never
Rarely
Sometimes
Usually
Always
9.
I get upset easily or feel panicky
Never
Rarely
Sometimes
Usually
Always
10.
I feel like I am falling apart and going to pieces
Never
Rarely
Sometimes
Usually
Always
11.
I feel that everything is all right and nothing bad will happen
Never
Rarely
Sometimes
Usually
Always
12.
My arms and legs shake and tremble
Never
Rarely
Sometimes
Usually
Always
13.
I am bothered by headaches, neck and back pains
Always
Usually
Sometimes
Rarely
Never
14.
I feel weak and get tired easily
A great deal
A lot
A moderate amount
A little
None at all
15.
I feel calm and can sit still easily
Always
Usually
Sometimes
Rarely
Never
16.
I can feel my heart beating fast
Always
Usually
Sometimes
Rarely
Never
17.
I am bothered by dizzy spells
Always
Usually
Sometimes
Rarely
Never
18.
I have fainting spells or feel faint
Always
Usually
Sometimes
Rarely
Never
19.
I can breathe in and out easily
Very easy
Easy
Neither easy nor difficult
Difficult
Very difficult
20.
I get feelings of numbness and tingling in my fingers and toes
Always
Usually
Sometimes
Rarely
Never
21.
I am bothered by stomachaches or indigestion
Never
Rarely
Sometimes
Usually
Always
22.
I have to empty my bladder often
Always
Usually
Sometimes
Rarely
Never
23.
My hands are usually dry and warm
Always
Usually
Sometimes
Rarely
Never
24.
My face gets hot and blushes
Never
Rarely
Sometimes
Usually
Always
25.
I fall asleep easily and get a good night's rest
Always
Usually
Sometimes
Rarely
Never
26.
I have nightmares
Always
Usually
Sometimes
Rarely
Never
27.
Any additional symptoms describing anxiety? Please include a rating of 0-4 with 0 meaning not at all, 4 meaning severe