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    • Are you an Empath?
    • Free Anxiety Questionnaire
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  • Free Anxiety Questionnaire

Free Anxiety Questionnaire

ANXIETY QUESTIONNAIRE

Complete the questionnaire below, by circling the relevant number next to the question after you have printed the form.  You can also write down the relevant answer (number) next to the question on a paper and add the total afterwards to get your results.

This questionnaire can assist you to find out if you might suffer from an anxiety disorder by calculating your symptoms and based on your answer, suggest if you suffer from mild to severe anxiety.

Question:  Over the past 7 days, have you experienced any of the following?  Choose an answer from the 7 Questions below:

Never Some Days More than 4 Days Every Day
1.  Feeling on the edge, nervous or anxious 0 1 2 3
2.  Not being able to control worrying 0 1 2 3
3.  Continuously worrying about different things 0 1 2 3
4.  Unable to Relax 0 1 2 3
5.  Feeling Restless 0 1 2 3
6.  Feeling Annoyed and Irritated 0 1 2 3
7.  Feeling fearful, as if expecting a negative event/situation/outcome 0 1 2 3
Add your Results per Column        
Total Score of All Columns        

 

Results:

Your total score is only a guide to determine how severe your anxiety may be:

0 – 4                = Mild Anxiety

5 – 9                = Moderate Anxiety

10 – 14            = Moderately Severe Anxiety

15 – 21             = Severe Anxiety

If you have scored 10 or higher, of if you feel that anxiety is affecting your day to day life, please register for a 60 min Coaching session, where your Transformation Coach, Jurie Fick, will share Information on what exactly causes Anxiety and Tips on how to deal with Anxiety and Stress.

 

Source:  Healthwise, Incorporated.

This information does not replace the advice of a doctor.  The Chrysalis Code Transformation Life Coaching disclaims any warranty or liability for your use of this information.

Get in touch

Tel : +27 60 5037415  Ansunette

Tel : +27 73 9409265  Jurie

ansunette@thechrysaliscode.com

jurie@thechrysaliscode.com

7 William Robertson Street, Swellendam, 6740

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  • Bipolar
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