JWFC The Burns Anxiety Inventory

Name*

First NameLast Name

Date

INSTRUCTIONS: The following is a list of symptoms that people sometimes have. Please click in the space to the right that bests describes how much that symptom or problem has bothered you during this past week.

Category 1: Anxious Feelings*

	0 NOT AT ALL	1 SOMEWHAT	2 MODERATELY	3 A LOT
1. Anxiety, Nervousness, Worry, and Fear
2. Feeling that things around you are strange, unreal or foggy
3. Feeling detached from all or part of your body
4. Sudden unexpected panic spells
5. Apprehension or a sense of impending doom
6. Feeling tense, stressed, "uptight," or on edge

1

Category 2: Anxious Thoughts*

	0 NOT AT ALL	1 SOMEWHAT	2 MODERATELY	3 A LOT
7. Difficulty concentration
8. Racing thoughts or your mind jumps from one thing to the next.
9. Frightening fantasies or daydreams
10.Feeling that you're on the verge of losing control
11.Fears of cracking up or going crazy
12.Fears of fainting or passing out
13.Fears of physical illness or heart attacks or dying
14.Concerns about looking foolish or inadequate in front of others
15.Fears of being alone, isolated, or abandoned
16. Fears of criticism or disapproval
17. Fears that something terrible is about to happen

2

Category 3: Physical Symptoms*

	0 NOT AT ALL	1 SOMEWHAT	2 MODERATELY	3 A LOT
18. Skipping or 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 back
32. Hot flashes or cold chills
33. Feeling tired, weak, or easily exhausted

3

This is your Total for the 33 symptoms:

Date

Name

First NameLast Name

Your Score is: Minimal or No Anxiety

Your Score is: 5-10 Borderline Anxiety

Your Score is: 11-20 Mild Anxiety

Your Score is: 21-30 Moderate Anxiety

Your Score is: 31-50 Severe Anxiety

Your Score is: 51-99 Extreme Anxiety or Panic

THE BURNS ANXIETY INVENTORY