| 1. |
Worried a lot about different things, even though nothing has happened or changed that should make you worry |
____ |
| 2. |
Vaguely apprehensive, as though something bad were about to happen, even though you don’t know what it is |
____ |
| 3. |
You try to keep busy and tell yourself there’s nothing to worry about, but just can’t shake this feeling |
____ |
| 4. |
Nervous and anxious, dreading the worst but not knowing what you’re afraid of in particular |
____ |
| 5. |
Wish you could stop worrying, but just can’t |
____ |
| 6. |
Even when you’re busy or having a good time that anxious feeling is in the background or creeps into what you’re doing |
____ |
|
|
II. Using the same scale, indicate whether the following
feelings have been a problem for you in the past three or four weeks? |
|
| 1. |
Feeling
nervous or jittery, characterized by any or all of the
following:
|
Heart
beats too fast or too hard |
|
“Butterflies”
in my stomach
|
|
Frequent
urination and/or diarrhea
|
|
Cold
fingers or clammy hands |
|
|
|
____ |
| 2. |
Get tired easily, with any or all of the following symptoms:
|
Tired
all the time |
|
Body
aches and pains
|
|
Headaches
|
|
Feel like I can’t get enough breath, taking big sighing breaths
|
|
Feel kind of weak, with pins-and-needles in arms and legs, or whole body |
|
____ |
| 3. |
Hard to concentrate, characterized by any or all of the following:
|
Mind goes blank when I’m talking or trying to remember things |
|
Absent-minded or forgetful (locking keys in car; leaving lunch or briefcase at home; forgetting appointments)
|
|
Losing
or misplacing things
|
|
Can’t
get organized, go “around in circles” |
|
Mind
wanders when I try to read or watch TV
|
|
____ |
| 4. |
Feel
grouchy or on-edge, including any or all of the following:
|
Impatient,
easily annoyed
|
|
“Short
fuse,” tend to “fly off the handle”
|
|
Fidgety,
restless, can’t sit still or stick with a task
|
|
Jumpy,
easily startled
|
|
Nervous
habits, like drumming fingers, biting nails
|
|
____ |
| 5. |
Tense muscles, feel “tied in knots,” with any or all of the following:
|
I
can’t seem to relax
|
|
Can’t
get sexually aroused very easily
|
|
Difficulty
swallowing
|
|
Feeling
of tightness in my head or chest
|
|
Clenched
teeth or tight jaw
|
|
____ |
| 6. |
Trouble
with sleep, characterized by any or all of the following:
|
Hard
time falling asleep
|
|
If I fall asleep I wake up “nervous” and can’t go back to sleep
|
|
Even when I sleep it’s
not restful, I “toss and turn”
|
|
I have bad dreams or
recurring anxious dreams
|
|
Feel kind of “afraid”
to go to bed or go to sleep
|
|
____ |
|
|
III. The next section of the questionnaire has to do with how difficult it’s been for you to do your work, take care of things at home or get along with other people. In the past three or four weeks, have your feelings interfered with any of the following areas of your life or behavior? |
|
|
0
= Not at all
1 = Only a little
2 = Sometimes
3 = A lot
4 = Almost all the time |
|
| 1. |
How you take care of personal business, e.g. paying bills, maintaining your car, cleaning your house, keeping appointments |
____ |
| 2. |
How you get along with people close to you, e.g. friends and
family members (or how they seem to get along with you) |
____ |
| 3. |
How
you do your job, e.g. meeting deadlines, being on time, calling
in sick, making mistakes, not seeming to get much done |
____ |
| 4. |
How you get along with people at work (or how they seem to
get along with you) |
____ |
| 5. |
How
you take care of yourself regarding such things as:
|
Bathing
|
|
Keeping
hair clean and well-groomed
|
|
Having
clothes clean and ready to wear
|
|
Preparing
meals or eating regularly
|
|
Taking
medications
|
|
____ |
| 6. |
How
you take care of your children or pets, regarding such things
as:
|
Feeding
|
|
Grooming
|
|
Attention
|
|
Exercise
or play
|
|
Routine
appointments, e.g., medical, lessons or training, sports
|
|
____ |
|
|
|
IV. If you’ve been anxious or worried in the past three or four weeks, circle a number below to indicate how bothered you are by these
feelings.
|
|
0
= Hardly at all
1
= Only a little bit
2
= Some
3
= A lot
4
= Almost more than I can handle
|