General Instructions: The questions below are designed to help health professionals evaluate anxiety symptoms. Keep in mind, a high score on this questionnaire does not necessarily mean you have an anxiety disorder — only an evaluation by a health professional can make this determination. Answer these questions as accurately as you can.
PART A Instructions: Please check YES or NO for the following questions, based on your experience in the past MONTH:
Have you been bothered by unpleasant thoughts or images that repeatedly enter your mind, such as:
Concerns with contamination (dirt, germs, chemicals, radiation) or acquiring a serious illness such as AIDS?*YesNo
Overconcern with keeping objects (clothing, tools, etc) in perfect order or arranged exactly?*YesNo
Images of death or other horrible event?*YesNo
Personally unacceptable religious or sexual thoughts?*YesNo
Have you worried a lot about terrible things happening, such as:
Fire, burglary or flooding of the house?*YesNo
Accidentally hitting a pedestrian with your car or letting it roll down a hill?*YesNo
Spreading an illness (giving someone AIDS)?*YesNo
Losing something valuable?*YesNo
Harm coming to a loved one because you weren’t careful enough?*YesNo
Have you worried about acting on an unwanted and senseless urge or impulse, such as:
Physically harming a loved one, pushing a stranger in front of a bus, steering your car into oncoming traffic; inappropriate sexual contact; or poisoning dinner guests?*YesNo
Have you felt driven to perform certain acts over and over again, such as:
Excessive or ritualized washing, cleaning or grooming?*YesNo
Checking light switches, water faucets, the stove, door locks or the emergency brake?*YesNo
Counting, arranging; evening-up behaviors (making sure socks are at same height)?*YesNo
Collecting useless objects or inspecting the garbage before it is thrown out?*YesNo
Repeating routine actions (in/out of chair, going through doorway, relighting cigarette) a certain number of times or until it feels just right?*YesNo
Needing to touch objects or people?*YesNo
Unnecessary rereading or rewriting; reopening envelopes before they are mailed?*YesNo
Examining your body for signs of illness?*YesNo
Avoiding colors (“red” means blood), numbers (“13” is unlucky) or names (those that start with “D” signify death) that are associated with dreaded events or unpleasant thoughts?*YesNo
Needing to “confess” or repeatedly asking for reassurance that you said or did something correctly?*YesNo
If you answered YES to one or more of these questions, please continue with Part B.
PART B Instructions: The following questions refer to the repeated thoughts, images, urges or behaviors identified in Part A. Consider your experience during the past 30 days when selecting an answer.
Select the most appropriate number from 0 to 4.
On average, how much time is occupied by these thoughts or behaviors each day?*NoneMild (less than 1 Hour)Moderate (1 to 3 Hours)Severe (3 to 8 Hours)Extreme (More than 8 hours)
How much distress do they cause you?*NoneMildModerateSevereExtreme (disabling)
How hard is it for you to control them?*Complete ControlMuch ControlModerate ControlLittle ControlNo Control
How much do they cause you to avoid doing anything, going anyplace or being with anyone?*No AvoidanceOccasional AvoidanceModerate AvoidanceFrequent and Extensive AvoidanceExtreme Avoidance (house-bound)
How much do they interfere with school, work or your social or family life?*NoneSlight InterferenceDefinitely interferes with functioningMuch InterferenceExtreme Interference (disabling)
Keep in mind, a high score on this questionnaire does not necessarily mean you have an anxiety disorder – only an evaluation by a health professional can make this determination.
© Wayne K. Goodman , MD , 1994.
6 + 0 = ? Please prove that you are human by solving the equation *
Frank Morelli MA, LMHC | 12412 San Jose Boulevard, Suite 401 Jacksonville, FL 32223-8620 | (904) 410-6324
This contact form is for informational purposes only. If this is a medical emergency, please contact 911 immediately for police assistance.
My office is easily accessible for those who live in Jacksonville, Orange Park, and Saint Augustine. If you would like to schedule an appointment, please contact me directly at (904) 410-6324.
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