Anxiety - Solis

Do you think you have anxiety?

Yes

No

Maybe

Do you feel afraid for no reason?

Never

Occasionally (1-2 times per month)

Sometimes (3-6 times per month)

Often (6 or more times per month)

Always

Do you have excess tension in your body, arms or legs?

Never

Occasionally (1-2 times per month)

Sometimes (3-6 times per month)

Often (6 or more times per month)

Always

Do you find it hard to catch your breath in certain situations, even though you are not exerting yourself?

Never

Occasionally (1-2 times over the last 6 months)

Sometimes (3-6 times over the last 6 months)

Often (6 or more times over the last 6 months)

Always

Have you lost or gained significant weight since the start of your symptoms?

Yes

No

If you gained weight, approximately how much have you gained?

If you lost weight, approximately how much have you lost?

Have you hurt yourself on purpose since your symptoms started?

Yes

No

If you answered yes to hurting yourself how badly did you hurt yourself?

I needed to go to hospital

I did not need to go to hospital but I needed medical treatment

I did not need medical treatment but am left with permanent scarring

I did not need medical treatment and have no permanent scarring

Has your sleep pattern changed since your symptoms began?

Yes

No

Not sure

How many hours sleep do you get a night currently?

1

2

3

4

5

6

7

8

9

10

11+

How many hours sleep did you get before your symptoms started?

1

2

3

4

5

6

7

8

9

10

11+

Has any life event lead to you feeling as you currently do? For example have you lost a loved one, been bullied or been in an accident?

Yes

No

Not sure

Do you feel jumpy, jittery or afraid for no good objective reason more than once per month?

Yes

No

Do you struggle to concentrate for longer than 15-20 minutes?

Yes

No

Sometimes (more than once per week)

I cannot concentrate even that long

Do you have thoughts of death - either your own, those of loved ones or do you think of large scale disasters?

Never

Occasionally (1-2 times per month)

Sometimes (3-6 times per month)

Often (6 or more times per month)

Always

Do you worry excessively even though you know that there is no real reason to worry?

Yes

No

Sometimes

How long have you had these symptoms?

Less than a month

More than 1 month but less than 3 months

More than 3 months but less than 6 months

Longer than 6 months but less than 2 years

Longer than 2 years

Does fear or worry interfere with your ability to do normal tasks such as shopping?

Never

Occasionally (1-2 times per month)

Sometimes (3-6 times per month)

Often (6 or more times per month)

Always

Does feeling anxious interfere with your ability to socialise?

Never

Occasionally (1-2 times per month)

Sometimes (3-6 times per month)

Often (6 or more times per month)

Always

Does feeling anxious interfere with your ability to go to work?

Never

Occasionally (1-2 times per month)

Sometimes (3-6 times per month)

Often (6 or more times per month)

Always

Do you faint more than once every 6 months?

Yes

No

Are you avoiding problems in your life by hiding away or leaving early?

Never

Occasionally (1-2 times per month)

Sometimes (3-6 times per month)

Often (6 or more times per month)

Always

Do you feel shame at your inability to overcome your fears, worries or anxieties?

Yes

No

If you have an existing physical health related diagnosis please let us know what it is below

If you have an existing mental health related diagnosis please let us know what it is below

Have you had therapy before? Please pick all that apply

CBT

Counselling

NLP (Neurolinguistic Programming)

DBT (Dialectic Behaviour Therapy)

Online CBT - Moodgym

Pyschodynamic

Psychiatric (In patient or out patient)

Person Centred Counselling

Psychotherapy

Cognitive Analytic Therapy

Family Therapy

Mindfulness

Specialist counselling

Psychoanalytic Therapy

Online Anxiety Assessment

A standardised test for symptoms of anxiety

Do you think you have anxiety?

Do you feel afraid for no reason?

Do you have excess tension in your body, arms or legs?

Do you find it hard to catch your breath in certain situations, even though you are not exerting yourself?

Have you lost or gained significant weight since the start of your symptoms?

If you gained weight, approximately how much have you gained?

If you lost weight, approximately how much have you lost?

Have you hurt yourself on purpose since your symptoms started?

If you answered yes to hurting yourself how badly did you hurt yourself?

Has your sleep pattern changed since your symptoms began?

How many hours sleep do you get a night currently?

How many hours sleep did you get before your symptoms started?

Has any life event lead to you feeling as you currently do? For example have you lost a loved one, been bullied or been in an accident?

Do you feel jumpy, jittery or afraid for no good objective reason more than once per month?

Do you struggle to concentrate for longer than 15-20 minutes?

Do you have thoughts of death - either your own, those of loved ones or do you think of large scale disasters?

Do you worry excessively even though you know that there is no real reason to worry?

How long have you had these symptoms?

Does fear or worry interfere with your ability to do normal tasks such as shopping?

Does feeling anxious interfere with your ability to socialise?

Does feeling anxious interfere with your ability to go to work?

Do you faint more than once every 6 months?

Are you avoiding problems in your life by hiding away or leaving early?

Do you feel shame at your inability to overcome your fears, worries or anxieties?

If you have an existing physical health related diagnosis please let us know what it is below

If you have an existing mental health related diagnosis please let us know what it is below

Have you had therapy before? Please pick all that apply

Are you currently on any medication? If so please tell us what it is

Is there anything else you would like us to know? Please tell us your experience as best you can

Get your answers