Below are descriptions of symptoms commonly associated with anxiety. Assign the client the rating between 0 and 4 (for each of the 14 items) that best describes the extent to which he/she has these symptoms.

0 = Not present

1 = Mild

2 = Moderate

3 = Severe

4 = Very severe

Rating

1. Anxious mood
   __________________
   Worries, anticipation of the worst, fearful anticipation, irritability
2. Tension
   __________________
   Feelings of tension, fatigability, startle response, moved to tears easily, trembling, feelings of restlessness, inability to relax
3. Fears
   __________________
   Of dark, of strangers, of being left alone, of animals, of traffic, of crowds
4. Insomnia
   __________________
   Difficulty in falling asleep, broken sleep, unsatisfying sleep and fatigue on waking, dreams, nightmares, night terrors
5. Intellectual
   __________________
   Difficulty in concentration, poor memory
6. Depressed mood
   __________________
   Loss of interest, lack of pleasure in hobbies, depression, early waking, diurnal swing
7. Somatic (muscular)
   __________________
   Pains and aches, twitching, stiffness, myoclonic jerks, grinding of teeth, unsteady voice, increased muscular tone
8. Somatic (sensory)
   __________________
   Tinnitus, blurred vision, hot/cold flushes, feelings of weakness, tingling sensation
9. Cardiovascular symptoms
   __________________
   Tachycardia, palpitations, pain in chest, throbbing of vessels, feeling faint
10. Respiratory symptoms
    __________________
    Pressure or constriction in chest, choking feelings, sighing, dyspnea
11. Gastrointestinal symptoms
    __________________
    Difficulty swallowing, flatulence, abdominal pain and fullness, burning sensations, nausea/vomiting, borborygmi, diarrhea, constipation, weight loss
12. Genitourinary symptoms
    __________________
    Urinary frequency, urinary urgency, amenorrhea, menorrhagia, loss of libido, premature ejaculation, impotence
13. Autonomic symptoms
    __________________
    Dry mouth, flushing, pallor, tendency to sweat, giddiness, tension headache
14. Behavior at interview
    __________________
    Fidgeting, restlessness or pacing, tremor of hands, furrowed brow, strained face, sighing or rapid respiration, facial pallor, swallowing, clearing throat

Client's Total Score __________________

SCORING:

• 14–17 = Mild Anxiety
• 18–24 = Moderate Anxiety
• 25–30 = Severe Anxiety