Form 0920- Beck Anxiety

Attachment D11

Beck Anxiety

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/20xx

Beck Anxiety

II. Below is a list of common symptoms of anxiety. Please read each item in the list carefully. Indicate how much you have been bothered by each symptom during the PAST WEEK by marking an “X” in the appropriate box.

	During the PAST WEEK	Not at all (1)	Did not bother me much (2)	Moderately (3)	Severely (4)
1	Numbness or tingling	□	□	□	□
2	Feeling hot	□	□	□	□
3	Wobbliness in legs	□	□	□	□
4	Unable to relax	□	□	□	□
5	Fear of the worst happening	□	□	□	□
6	Dizzy or lightheaded	□	□	□	□
7	Heart pounding or racing	□	□	□	□
8	Unsteady	□	□	□	□
9	Terrified	□	□	□	□
10	Nervous	□	□	□	□
11	Feelings of choking	□	□	□	□
12	Hands trembling	□	□	□	□
13	Shaky	□	□	□	□
14	Fear of losing control	□	□	□	□
15	Difficulty breathing	□	□	□	□
16	Fear of dying	□	□	□	□
17	Scared	□	□	□	□
18	Indigestion or discomfort in abdomen	□	□	□	□
19	Faint	□	□	□	□
20	Face flushed	□	□	□	□
21	Sweating (not due to heat)	□	□	□	□

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