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Full Name
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E-mail
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Phone Number
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Law Firm Name
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Law Firm Phone
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Below is a list of problems and complaints that people sometimes have in response to stressful life experiences. Please read each one carefully. Then enter the appropriate number in the right-hand column to show how much you have been bothered by that problem in the last month.
1= Not at all, 2= A little bit, 3 = Moderately, 4=Quite a bit, 5=Extremely
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Repeated, disturbing memories, thoughts, or images of a stressful experience from the past.
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Repeated, disturbing dreams of a stressful experience from the past.
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Suddenly acting or feeling as if a stressful experience were happening again (as if you were reliving it).
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Feeling very upset when something reminded you of a stressful experience from the past.
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Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of a stressful experience from the past.
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Avoiding thinking about or talking about a stressful experience from the past or avoiding having feelings related to it.
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Avoiding activities or situations because they remind you of a stressful experience from the past.
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Trouble remembering important parts of a stressful experience from the past.
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Loss of interest in activities that you used to enjoy.
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Feeling distant or cut off from other people.
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Feeling emotionally numb or being unable to have loving feelings for those close to you.
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Feeling as if your future will somehow be cut short.
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Trouble falling or staying asleep.
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Feeling irritable or having angry outbursts.
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Having difficulty concentrating.
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Being "super-alert" or watchful or on guard.
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Feeling jumpy or easily startled.
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Add up each score to obtain your total score. If your total score is:
0 – 10: No symptoms of Anxiety
17 – 20: No to minimum symptoms of Anxiety
21 – 29: Mild symptoms of Anxiety
30 - 49: Moderate symptoms of Anxiety
50 – 86: Severe symptoms of Anxiety
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