"*" indicates required fields Name* First name What type of anxiety do you suffer from? PTSD Generalised Anxiety Social Anxiety Health Anxiety OCD Environmental Anxiety Several of the above None of the above How often have you been feeling anxious? Nearly every day Several days More than half the days Not at all As a child did you suffer from any of the following types of abuse? Psychological Sexual Physical Neglect Bullying Racial None of the above What's the biggest challenge that anxiety has presented to you so far? Problems sleeping Relationship problems Problems with work Problems dating None of the above How often have you been bothered by not being able to stop or control worrying? Nearly every day Several days More than half the days Not at all Have you ever had a panic attack? Yes No If this questionnaire has highlighted any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Somewhat difficult Very difficult Extremely difficult Not difficult at all To deal with your anxiey and feelings of loneliness have you ever done any of the following? Eaten excessively Used alcohol excessively Smoked excessively Taken illegal drugs Been violent towards others Viewed pornography frequently Gambled money Had casual sex None of the above E-mail*
