Adult Anxiety Checklist
Assess your anxiety symptoms by completing this self-assessment checklist.
Full Name
*
First Name
Last Name
Age
*
Gender
Male
Female
Non-binary
Prefer not to say
Email Address
example@example.com
How often have you experienced the following symptoms in the past two weeks?
*
Rows
Never
Rarely
Sometimes
Often
Almost Always
Feeling nervous, anxious, or on edge
1
2
3
4
5
Not being able to stop or control worrying
6
7
8
9
10
Worrying too much about different things
11
12
13
14
15
Trouble relaxing
16
17
18
19
20
Being so restless that it's hard to sit still
21
22
23
24
25
Becoming easily annoyed or irritable
26
27
28
29
30
Feeling afraid as if something awful might happen
31
32
33
34
35
How would you rate your overall anxiety level today?
*
1
2
3
4
5
Have you previously been diagnosed with an anxiety disorder?
Yes
No
Prefer not to say
Are you currently receiving support or treatment for anxiety?
Yes
No
Prefer not to say
How much do anxiety symptoms interfere with your daily life?
*
Not at all
1
2
3
4
5
6
7
8
9
Extremely
10
1 is Not at all, 10 is Extremely
Please share any additional comments or concerns about your anxiety.
Submit Checklist
Should be Empty: