ANXScreen

            Name:_____________________________________

Answer Yes or No – then elaborate if needed!

Return ASAP – next visit or mail back.

1.    Do you worry about things such as work or school more days than not?

2.    Do you find it difficult to stop thoughts related to worrying?

3.    Do you often feel restless or on edge even when nothing is going

        on around you to cause it?

4.    Is it hard for you to concentrate on specific tasks or do you

        often get distracted from what you are doing?

5.    Do you often feel irritable or tense for no particular reason?

6.    Is it difficult for you to fall asleep due to too many thoughts in your head?

7.    Do you frequently notice your muscles getting tense, especially your lower

        back, neck or eyes?

8.    Do you find it difficult to sit still without having to fiddle

        with something, doodle, or make other repetitious movements?

9.    Have you noticed periods during the day when you have symptoms

        such as heart palpitations, sweaty palms, or shallow breathing?

10.    Do friends or family members tell you that you are too high

           strung, worry too much about little things, or need to 'chill out?'