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	The Phobia King's Home Page   |   home Guest Book, Comments/Suggestions/Questions   |   What is anxiety?   |   Anxiety Evaluation   |   Stress Response   |   relaxation response   |   What is a phobia?   |   What is agoraphobia?   |   Do you want help now?   |   Self  help resources   |   About the author   |   Consultation   |   -List 500 Phobia's- back Anxiety Evaluation Check below the situations and events that are uncomfortable for you, do to your anxiety symptoms. Besides each, using the two scales below, indicate how often you would avoid the situation or event and how much anxiety you would feel in that situation. If there is a particular situation or event that bothers you that is not listed, please feel free to add it at the bottom.      Level of avoidance scale             Level of anxiety scale           1- never avoid                           1- minimum anxiety           2- sometimes avoid                  2- moderate anxiety           3- often avoid                            3- extreme anxiety           4- always avoid                        4- panic feelings       Event                                        Level of Avoidance    Level of Anxiety Shopping in stores                       ____________          ____________ Eating in restaurants                    ____________          ____________ Eating in front of people               ____________          ____________ Writing checks                              ____________          ____________ Driving                                           ____________          ____________ Traveling distances                      ____________          ____________ Standing in lines                           ____________          ____________ Heights                                          ____________          ____________ Bridges                                         ____________          ____________ Sitting in meetings                       ____________          ____________ Enclosed areas                           ____________          ____________ Going to church                            ____________          ____________ Socializing with people               ____________          ____________ Flying                                            ____________          ____________ Talking in front of others              ____________          ____________ Crowded areas                            ____________          ____________ Being alone                                  ____________          ____________ Other                                             ____________          ____________ Check below any of the body symptoms you experience during an anxious period. ( )  racing heart/chest                                                  ( ) discomfort  nausea ( )  trembling/nervousness                                          ( ) hot or cold flashes ( )  dizziness                                                                 ( ) muscle tension ( )  feeling confused and bewildered                         ( ) headaches ( )  diarrhea                                                                  ( ) insomnia/sleeping to much ( )  shortness of breath                                                ( ) restless feelings ( )  numbness in various parts of the body                                                                                       ( ) strange thoughts ( )  feelings of fatigue and depression                                                                                       ( ) feelings of helplessness ( )  unexplainable panicky feelings                            ( ) uncontrollable bouts of anger How much do these symptoms bother you? Circle the appropriate answer.              Not much      Moderately      Extremely How many times per week do you have panic attacks? When was your last panic attach? During a typical day, how much time do you spend worrying about this problem? ________________ Are you on medication for anxiety or depression? _______________________________________ What kind? ________________ Dosage? __________________ Have you seen a doctor for this problem? _________ Who? ____________ How long? __________ What bothers you most about this condition? ___________________________________________ How much does this condition disrupt your life? Circle the appropriate answer.       Not much      Moderately      Extremely Where did you hear about my site? __________________________________________________ Comments about your problem: _____________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Note: This is to help you become aware, discover, any avoidance patterns or symptoms  you may not have been aware of before, or thought were normal. What is anxiety?