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.
Country of Residence
Confirm your email address
Phone including area code
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?
Generalized Anxiety Disorder
Post Traumatic Stress Disorder
Social Anxiety Disorder
Pure O (Inappropriate thoughts)
Night-time panic attacks
Fear of dying
What symptoms do you experience?
Numbness, tingling in head
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
Skin blanching (paleness)
Inability to take a deep breath
Acid indigestion / reflux
Urgency to urinate
Urgency to defecate
Belching / bloating
Stomach pain, cramps, distension
Tingling in legs or feet
Abnormal / delayed menstrual cycle
Feeling like being pushed over
What thoughts do you experience?
Anxiety about your health
Fear of death
Fear of medical procedures
Thoughts about existence
Compulsive thoughts / rituals
Feeling lost or confused
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
Your lifestyle and habits
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?
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.