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.
  • Your symptoms

    Please be as honest as you can with your answers - This information will not be divulged to a third party.
  • YES
    Generalized Anxiety Disorder
    Panic Attacks
    Post Traumatic Stress Disorder
    Eating Disorder
    Social Anxiety Disorder
    Health Anxiety
    Pure O (Inappropriate thoughts)
    Postnatal/Postpartum Anxiety/Depression
    Low mood
    Night-time panic attacks
    Fear of dying
  • YES
    Chest pain
    Racing heart
    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
    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
    Weak legs
    Shaky legs
    Tingling in legs or feet
    Muscle pains
    Abnormal / delayed menstrual cycle
    Feeling like being pushed over
  • 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
    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
  • 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?
  • 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.