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Anxiety Questionnaire
Please fill the details
Would you prefer your consultation ? *
What is your preference for days? *
What are your preferences for timings? *
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, blurring of vision, hot and cold flushes, feelings of weakness, pricking sensation. *
9. Cardiovascular symptoms: Tachycardia, palpitations, pain in chest, throbbing of vessels, fainting feelings, missing beat. *
10. Respiratory symptoms: Pressure or constriction in chest, choking feelings, sighing, dyspnea. *
11. Gastrointestinal symptoms: Difficulty in swallowing, wind abdominal pain, burning sensations, abdominal fullness, nausea, vomiting, borborygmi, looseness of bowels, loss of weight, constipation. *
12. Genitourinary symptoms: Frequency of micturition, urgency of micturition, amenorrhea, menorrhagia, development of frigidity, premature ejaculation, loss of libido, impotence. *
13. Autonomic symptoms: Dry mouth, flushing, pallor, tendency to sweat, giddiness, tension, headache, raising of hair. *
14. Behavior at interview: Fidgeting, restlessness or pacing, tremor of hands, furrowed brow, strained face, sighing or rapid respiration, facial pallor, swallowing, etc. *