Beck Anxiety Inventory

Beck Anxiety Inventory
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Who is your provider*
Beck Anxiety Inventory (BAI)

Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much you have been bothered by that symptom during the past month, including today.*

	Not At All	Mildly but it didn’t bother me much	Moderately - it wasn’t pleasant at times	Severely – it bothered me a lot
Numbness or tingling
Feeling hot
Wobbliness in legs
Unable to relax
Fear of worst happening
Dizzy or lightheaded
Heart pounding/racing
Unsteady
Terrified or afraid
Nervous
Feeling of choking
Hands trembling
Shaky / unsteady
Fear of losing control
Difficulty in breathing
Fear of dying
Scared
Indigestion
Faint / lightheaded
Face flushed
Hot/cold sweats

BAI Total Score
Score of 0-21 = low anxiety
Score of 22-35 = moderate anxiety
Score of 36 and above = potentially concerning levels of anxiety
Date

MonthDayYear
Date
Should be Empty:

Beck Anxiety Inventory

Beck Anxiety Inventory (BAI)