Circle or mark one number for each item that best describes how much you have experienced each symptom
over the past week.
1. Feeling nervous 0 1 2 3
2. Worrying 0 1 2 3
3. Trembling, twitching, feeling shaky 0 1 2 3
4. Muscle tension, muscle aches, muscle soreness 0 1 2 3
5. Restlessness 0 1 2 3
6. Tiring easily 0 1 2 3
7. Shortness of breath 0 1 2 3
8. Rapid heartbeat 0 1 2 3
9. Sweating not due to the heat 0 1 2 3
10. Dry mouth 0 1 2 3
11. Dizziness or light- headedness 0 1 2 3
12. Nausea, diarrhea, or stomach problems 0 1 2 3
13. Increase in urge to urinate 0 1 2 3
14. Flushes (hot ashes) or chills 0 1 2 3
15. Trouble swallowing or “lump in throat” 0 1 2 3
16. Feeling keyed up or on edge 0 1 2 3
17. Being quick to startle 0 1 2 3
18. Diculty concentrating 0 1 2 3
19. Trouble falling or staying asleep 0 1 2 3
20. Irritability 0 1 2 3
21. Avoiding places where I might be anxious 0 1 2 3
22. Thoughts of danger 0 1 2 3
23. Seeing myself as unable to cope 0 1 2 3
24. Thoughts that something terrible will happen 0 1 2 3
(sum of item scores)
From
Mind Over Mood, Second Edition.
Copyright 2016 by Dennis Greenberger and Christine A. Padesky.