Beck Anxiety Inventory Below is a list of common symptoms of anxiety. Answer these questions based on how you are feeling today. Patient Name(Required) First Last Today’s Date MM slash DD slash YYYY 1. Numbness or tingling Not At All Mildly but it didn’t bother me much. Moderately – it wasn’t pleasant at times Severely – it bothered me a lot 2. Feeling hot Not At All Mildly but it didn’t bother me much. Moderately – it wasn’t pleasant at times Severely – it bothered me a lot 3. Wobbliness in legs Not At All Mildly but it didn’t bother me much. Moderately – it wasn’t pleasant at times Severely – it bothered me a lot 4. Unable to relax Not At All Mildly but it didn’t bother me much. Moderately – it wasn’t pleasant at times Severely – it bothered me a lot 5. Fear of worst happening Not At All Mildly but it didn’t bother me much. Moderately – it wasn’t pleasant at times Severely – it bothered me a lot 6. Dizzy or lightheaded Not At All Mildly but it didn’t bother me much. Moderately – it wasn’t pleasant at times Severely – it bothered me a lot 7. Heart pounding/racing Not At All Mildly but it didn’t bother me much. Moderately – it wasn’t pleasant at times Severely – it bothered me a lot 8. Unsteady Not At All Mildly but it didn’t bother me much. Moderately – it wasn’t pleasant at times Severely – it bothered me a lot 9. Terrified or afraid Not At All Mildly but it didn’t bother me much. Moderately – it wasn’t pleasant at times Severely – it bothered me a lot 10. Nervous Not At All Mildly but it didn’t bother me much. Moderately – it wasn’t pleasant at times Severely – it bothered me a lot 11. Feeling of choking Not At All Mildly but it didn’t bother me much. Moderately – it wasn’t pleasant at times Severely – it bothered me a lot 12. Hands trembling Not At All Mildly but it didn’t bother me much. Moderately – it wasn’t pleasant at times Severely – it bothered me a lot 13. Shaky / unsteady Not At All Mildly but it didn’t bother me much. Moderately – it wasn’t pleasant at times Severely – it bothered me a lot 14. Fear of losing control Not At All Mildly but it didn’t bother me much. Moderately – it wasn’t pleasant at times Severely – it bothered me a lot 15. Difficulty in breathing Not At All Mildly but it didn’t bother me much. Moderately – it wasn’t pleasant at times Severely – it bothered me a lot 16. Fear of dying Not At All Mildly but it didn’t bother me much. Moderately – it wasn’t pleasant at times Severely – it bothered me a lot 17. Scared Not At All Mildly but it didn’t bother me much. Moderately – it wasn’t pleasant at times Severely – it bothered me a lot 18. Indigestion Not At All Mildly but it didn’t bother me much. Moderately – it wasn’t pleasant at times Severely – it bothered me a lot 19. Faint / lightheaded Not At All Mildly but it didn’t bother me much. Moderately – it wasn’t pleasant at times Severely – it bothered me a lot 20. Face flushed Not At All Mildly but it didn’t bother me much. Moderately – it wasn’t pleasant at times Severely – it bothered me a lot 21. Hot/cold sweats Not At All Mildly but it didn’t bother me much. Moderately – it wasn’t pleasant at times Severely – it bothered me a lot Total Δ
