EmailMeForm
Anxiety Assessment Form
Please fill in the form and click submit. Your assessment will be responded to by one of our qualified Specialists. The details you provide are dealt with in the strictest confidence.
Name
*
First
Last
Your age
*
Country of Residence
*
Your gender
*
Email
*
Confirm your email address
Phone including area code
*
Your symptoms
Please be as honest as you can with your answers - This information will not be divulged to a third party.
What conditions do you experience?
YES
Generalized Anxiety Disorder
Panic Attacks
Agoraphobia
OCD
Post Traumatic Stress Disorder
Eating Disorder
Social Anxiety Disorder
Health Anxiety
Pure O (Inappropriate thoughts)
Self-Harming
Postnatal/Postpartum Anxiety/Depression
Low mood
Night-time panic attacks
Fear of dying
What symptoms do you experience?
YES
Palpitations
Chest pain
Racing heart
Dizziness
Faintness
Head pain
Numbness, tingling in head
Neck pain
Shoulder pain
Back pain
Heaviness in arm/s
Tingling/pins and needles in limbs
Heaviness in arm/s
Shortness of breath
Strange taste in mouth
Lump in throat / difficulty swallowing
Choking sensation
Dry mouth
Sweating
Skin blanching (paleness)
Smothering sensation
Dry eyes
Inability to take a deep breath
Tight chest
Nausea /sickness
Acid indigestion / reflux
Urgency to urinate
Urgency to defecate
Belching / bloating
Stomach pain, cramps, distension
Diarrhoea
Constipation
IBS
Weak legs
Shaky legs
Tingling in legs or feet
Muscle pains
Abnormal / delayed menstrual cycle
Feeling like being pushed over
What thoughts do you experience?
YES
Obsessive thoughts
Aggressive thoughts
Sexual thoughts
Homosexual thoughts
Religious thoughts
Anxiety about your health
Fear of death
Fear of medical procedures
Thoughts about existence
Compulsive thoughts / rituals
Feeling lost or confused
Depressive thoughts
Depersonalization
Derealization
Confusion
Loss of libido (sexual appetite)
Loss of feelings of love for others
Loss of concentration
Feelings of being unable to cope
A sense of impending doom
A sense of living outside of your body
Fear of vomiting
Health anxiety
Your lifestyle and habits
*
YES
NO
Do you smoke?
Do you drink alcohol?
Do you take illegal drugs?
Do you go to the gym or run/cycle?
Do you take prescription medication for anxiety?
Do you take prescription medication for anything else?
Do you drink caffeine containing drinks?
Do you drink energy drinks?
Do you take dietary supplements?
Are you overweight?
Do you suffer from diabetes or other endocrine disorders?
Have you ever been diagnosed with depression?
Have you ever had Cognitive Therapy? (CBT)
Have you ever had hypnosis?
Have you ever been hospitalized for your condition?
How influential is anxiety in your life?
It is ruining my life
It is a constant negative influence
It impairs everything I do
I need to get rid of it
It doesn't stop me doing things
It is constant but not catastrophic
It doesn't really bother me too much
How ready are you to become anxiety disorder free?
Extremely
Very
Quite
Not sure
Not at all
Identify which are the most overwhelming symptoms or condition
Any other details you think might help us to help you
Please write anything in the box above that you feel might be relevant to your condition.
Your assessment will be handled by an accredited Anxiety Recovery Expert.
