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Mild: Occasionally

Moderate: Less than half the time

Severe: More than half the time

Incapacitating: Severe enough to interfere with whatever you are going

Question Absent Mild Moderate Severe Incapacitating
1. Is your mood anxious?
  • You worry a lot
  • You anticipate the worst in any situation
2. Do you feel tense?
  • Do you startle easily, cry easily, feel restless or tremble often?
3. Are you experiencing fear?
  • Fear of the dark
  • Fear of strangers
  • Fear of being alone
  • Fear of animal
4. Are you suffering from insomnia?
  • Difficulty falling asleep or staying asleep
  • Difficulty with nightmares
5. How is your intellectual state?
  • Poor concentration
  • Memory impairment
6. Do you suffer from depressed mood?
  • Decreased interest in activities
  • Anhedonia (loss of joy in activities you earlier enjoyed)
  • Anergia (feel you lack energy)
7. Do you have muscular somatic complaints?
  • Muscle aches or pains
  • Bruxism (grinding of teeth in sleep or during the day)
8. Do you have sensory complaints?
  • Tinnitus (ringing or buzzing sound in the ears)
9. Do you have cardiovascular symptoms?
  • Tachycardia (an abnormally rapid heart rate)
  • Palpitations (a noticeably rapid; strong; or irregular heartbeat due to agitation; exertion; or illness)
  • Chest pain
  • Sensation of
10. Do you have respiratory symptoms?
  • Chest pressure
  • Choking sensation
  • Shortness of breath
11. Do you have gastrointestinal symptoms?
  • Dysphagia
  • Nausea or vomiting
  • Constipation
  • Weight loss
12. Do you have genitourinary symptoms?
  • Urinary frequency or urgency
  • Dysmenorrhea (pain during periods)
  • Impotence
13. Do you have autonomic symptoms?
  • Dry mouth
  • Flushing
  • Pallor
  • Sweating
14. Do you experience the following in an interview?
  • Fidgeting
  • Tremors
  • Restlessness
  • Need to pace up and down