Dr. Nioka’s Anxiety Screening

Name *

First Name

Last Name

Numbness or tingling *

0-None

1-Mild

2-Moderate

3-Severe

Dizziness *

0-None

1-Mild

2-Moderate

3-Severe

Chest Pain *

0-None

1-Mild

2-Moderate

3-Severe

Headaches *

0-None

1-Mild

2-Moderate

3-Severe

Neck Tension *

0-None

1-Mild

2-Moderate

3-Severe

Stomach upset, Nervous stomach *

0-None

1-Mild

2-Moderate

3-Severe

Fear of impending doom *

0-None

1-Mild

2-Moderate

3-Severe

Nausea *

0-None

1-Mild

2-Moderate

3-Severe

Shortness of breath *

0-None

1-Mild

2-Moderate

3-Severe

Electric Shock feeling *

0-None

1-Mild

2-Moderat

3-Severe

Shooting Pains in the face *

0-None

1-Mild

2-Moderate

3-Severe

Heart Palpitations *

0-None

1-Mild

2-Moderate

3-Severe

Weakness in legs *

0-None

1-Mild

2-Moderate

3-Severe

Feeling like you're going crazy *

0-None

1-Mild

2-Moderate

3-Severe

Inability to rest *

0-None

1-Mild

2-Moderate

3-Severe

Sleep Problems *

0-None

1-Mild

2-Moderate

3-Severe

Indigestion *

0-None

1-Mild

2-Moderate

3-Severe

Face Flushed *

0-None

1-Mild

2-Moderate

3-Severe

Fear of losing control *

0-None

1-Mild

2-Moderate

3-Severe

Feeling hot *

0-None

1-Mild

2-Moderate

3-Severe

Fear of dying *

0-None

1-Mild

2-Moderate

3-Severe

Problems with swallowing *

0-None

1-Mild

2-Moderate

3-Severe