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Please complete all sections of the form below to receive an automated screening for a variety of anxiety conditions. Mark the symptoms you experience.



  1. During my worst panic I had three or more of the following symptoms:













5

  1. I have high levels of anxiety or avoid situations where people might judge or evaluate me in a social setting such as one or more of the following:






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  1. I have at least three of the following symptoms when I'm worried or anxious:







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  1. I do not have panic attacks but I do have strong fear of one or more of the following and that fear has caused me to avoid the feared object or situation, or endure it with great diffculty:
    insects or animals such as bees, bats, cats, dogs, mice, rats, snakes, spiders
    elevators
    airplanes or flying
    thunder or lightening
    doctors or dentists
    needles
    blood
    water
    disease or illness
    darkness or closed in spaces
    other



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  1. I have recurring and unwanted thoughts such as hurting someone, being contaminated by dirt, germs, or some toxic substance, or of some catastrophe occurring. Furthermore, I realize that these thoughts are irrational and not likely to occur, however, I still can't stop the thoughts and they occur frequently enough to interfere with my enjoyment of life in some way.
  2. I have repetitive actions or behaviors such as counting, washing my hands, checking doors, locks, or appliances that are done to relieve anxiety or worry about irrational fears that come to my mind. These behaviors occur frequently enough to interfere with my enjoyment of life in some way.


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  1. I have significant anxiety, worry, and intrusive thoughts, nightmares, or flashbacks to an event in my life where I either witnessed or was in a position where serious harm occurred to me or where serious harm or death occurred to someone else. My symptoms are severe enough to interfere with my enjoyment of life or relationships in some way.

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