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.