Anxiety Scale Name* First Last Date of birth MM slash DD slash YYYY Please answer the following questions1. Difficulty breathing* Not at all Mildly (it did not bother me much) Moderately (It was very unpleasant but I could stand it) Severely (I could barely stand it) 2. Difficulty sleeping at night* Not at all Mildly (it did not bother me much) Moderately (It was very unpleasant but I could stand it) Severely (I could barely stand it) 3. Dizzy or lightheaded* Not at all Mildly (it did not bother me much) Moderately (It was very unpleasant but I could stand it) Severely (I could barely stand it) 4. Face flushed* Not at all Mildly (it did not bother me much) Moderately (It was very unpleasant but I could stand it) Severely (I could barely stand it) 5. Faint* Not at all Mildly (it did not bother me much) Moderately (It was very unpleasant but I could stand it) Severely (I could barely stand it) 6. Fear of dying* Not at all Mildly (it did not bother me much) Moderately (It was very unpleasant but I could stand it) Severely (I could barely stand it) 7. Fear of losing control* Not at all Mildly (it did not bother me much) Moderately (It was very unpleasant but I could stand it) Severely (I could barely stand it) 8. Fear of the worst happening* Not at all Mildly (it did not bother me much) Moderately (It was very unpleasant but I could stand it) Severely (I could barely stand it) 9. Feeling hot* Not at all Mildly (it did not bother me much) Moderately (It was very unpleasant but I could stand it) Severely (I could barely stand it) 10. Feeling hot* Not at all Mildly (it did not bother me much) Moderately (It was very unpleasant but I could stand it) Severely (I could barely stand it) 11. Feelings of choking* Not at all Mildly (it did not bother me much) Moderately (It was very unpleasant but I could stand it) Severely (I could barely stand it) 12. Hands trembling* Not at all Mildly (it did not bother me much) Moderately (It was very unpleasant but I could stand it) Severely (I could barely stand it) 13. Heart pounding or racing* Not at all Mildly (it did not bother me much) Moderately (It was very unpleasant but I could stand it) Severely (I could barely stand it) 14. Indigestion or discomfort in abdomen* Not at all Mildly (it did not bother me much) Moderately (It was very unpleasant but I could stand it) Severely (I could barely stand it) 15. Nervous* Not at all Mildly (it did not bother me much) Moderately (It was very unpleasant but I could stand it) Severely (I could barely stand it) 16. Numbness or tingling* Not at all Mildly (it did not bother me much) Moderately (It was very unpleasant but I could stand it) Severely (I could barely stand it) 17. On edge* Not at all Mildly (it did not bother me much) Moderately (It was very unpleasant but I could stand it) Severely (I could barely stand it) 18. Racing thoughts* Not at all Mildly (it did not bother me much) Moderately (It was very unpleasant but I could stand it) Severely (I could barely stand it) 19. Shaky* Not at all Mildly (it did not bother me much) Moderately (It was very unpleasant but I could stand it) Severely (I could barely stand it) 20. Sweating (not due to heat)* Not at all Mildly (it did not bother me much) Moderately (It was very unpleasant but I could stand it) Severely (I could barely stand it) 21. Terrified* Not at all Mildly (it did not bother me much) Moderately (It was very unpleasant but I could stand it) Severely (I could barely stand it) 22. Unable to relax* Not at all Mildly (it did not bother me much) Moderately (It was very unpleasant but I could stand it) Severely (I could barely stand it) 23. Wobbliness in legs* Not at all Mildly (it did not bother me much) Moderately (It was very unpleasant but I could stand it) Severely (I could barely stand it) HiddenDate of submission MM slash DD slash YYYY