Kirstin R. Abraham, LCSW

Instructions: Place a check in the space to the right that best describes how much each symptom or problem has bothered you during the past week.

Rating Scale: 0 = Not at all, 1 = Somewhat, 2 = Moderately, 3 = A lot

By submitting this form, you acknowledge that the information provided is accurate to the best of your knowledge. This inventory is a screening tool and does not constitute a clinical diagnosis.

Burns Anxiety Inventory

Anxious Feelings

1. Anxiety, nervousness, worry, or fear

2. Feeling that things around you are strange or unreal

3. Feeling detached from all or part of your body

4. Sudden unexpected panic spells

Anxious Thoughts

5. Apprehension or a sense of impending doom

6. Feeling tense, stressed, "uptight," or on edge

7. Difficulty concentrating

8. Racing thoughts

9. Frightening fantasies or daydreams

10. Feeling that you're on the verge of losing control

Physical Symptoms

11. Fears of cracking up or going crazy

12. Fears of fainting or passing out

13. Fears of physical illnesses or heart attacks or dying

14. Concerns about looking foolish or inadequate

15. Fears of being alone, isolated, or abandoned

16. Fears of criticism or disapproval

17. Fears that something terrible is about to happen

18. Skipping, racing, or pounding of the heart (palpitations)

19. Pain, pressure, or tightness in the chest

20. Tingling or numbness in the toes or fingers

21. Butterflies or discomfort in the stomach

22. Constipation or diarrhea

23. Restlessness or jumpiness

24. Tight, tense muscles

25. Sweating not brought on by heat

26. A lump in the throat

27. Trembling or shaking

28. Rubbery or "jelly" legs

29. Feeling dizzy, lightheaded, or off balance

30. Choking or smothering sensations or difficulty breathing

31. Headaches or pains in the neck or shoulders

32. Feeling tired, weak, or easily exhausted

33. Difficulty falling or staying asleep

Signature *