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Anxiety Disorder Recovery Assessment

Submit to have one of our Recovery Specialists assess your disorder.

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Question 1 of 15

How long have you suffered?

(Select all that apply)
A

1-6 months

B

6-12 months

C

1-2 years

D

2-5 years

E

5-10 years

F

10+ years

Question 2 of 15

Do you work?

(Select all that apply)
A

I am a student

B

I do not work

C

I work part time

D

I work full time

E

I am retired

F

I lost my job

G

I am under 18 years

Question 3 of 15

If you are a student or have a job, how many hours do you spend working each day?

(Select all that apply)
A

1-3 hours

B

3-6 hours

C

6-9 hours

D

I do not work and am not a student

Question 4 of 15

Have you tried other treatments? 

(Select all that apply)
A

Counselling

B

Medication

C

Cognitive Therapy

D

Hypnosis

E

Tapping (EFT)

F

Meditation

G

Mindfulness

H

Other

Question 5 of 15

Do you take medication for your anxiety?

(Select all that apply)
A

Yes

B

No

C

Sometimes

D

I use natural medications

Question 6 of 15

Has anyone ever told you that your condition cannot be cured?

(Select all that apply)
A

Yes

B

No

Question 7 of 15

Do you believe that full recovery from your anxiety condition is possible?

A

Yes

B

No

C

Unsure

Question 8 of 15

How old are you?

A

10-20

B

20-30

C

30-40

D

40-50

E

50-60

F

60+

G

Rather not say

Question 9 of 15

Which of these do you experience?

(Select all that apply)
A

Generalised anxiety disorder

B

Panic attacks

C

Agoraphobia

D

Emetophobia

E

Monophobia

F

Depersonalisation or derealisation

G

Eating disorder - Bulimia, anorexia or other

H

Health anxiety

I

Fear of dying or fainting

J

Intrussive thoughts - sexual, homosexual, paedophilic, relationship, religion, aggressive etc.

K

Lump in your throat

L

Irritable bowel syndrome

M

Post traumatic stress

N

Insomnia

O

Social Phobia

Question 10 of 15

Do you experience any of these symptoms?

(Select all that apply)
A

Dizziness or faintness

B

Heart palpitations or racing heart

C

Blurred vision

D

Unexplained sweating

E

Ringing or noises in ears

F

Dry eyes or mouth

G

Shortness of breath or a smothering sensation

H

Chest pain

I

Digestive issues, diarrhoea, indigestion or abdominal pain

J

Tingling in hands or feet

K

Shaky legs

L

Neck or shoulder tension

M

Blushing or flushing on chest

N

Skin blanching (looking pale)

O

Hormone issues such as periods stopping or changing

P

Inappropriate aggressive outbursts

Q

Loss of libido (sexual appetite)

R

Impotence (Inability to get an erection) or lack of sensitivity in male or female genitals

S

Unusual sensations such as tingling or numbness in face, head, or extremeties

Question 11 of 15

How limited is your life by your condition?

(Select all that apply)
A

10% less capable

B

20% less capable

C

30% less capable

D

40% less capable

E

50% less capable

F

60% less capable

G

70-100% less capable

Question 12 of 15

Is your partner or family supportive?

A

Yes

B

No

C

Most of the time

D

Not very often

Question 13 of 15

Do you ever feel like you are too scared to live but too scared to die?

(Select all that apply)
A

Yes

B

No

Question 14 of 15

If you do ever feel desperate, please call our team on +44(0)1562 702720 or email [email protected] - NEVER be alone with those thoughts. You could also call your family clinic or the Samaritans. Please write anything pertaining to your feelings here if you wish to share them with us.

Question 15 of 15

Would you like us to call you or email you with information about our residential, workshop or online recovery programs?

 

If so, please enter your phone number and email address in the box below.

 

When you have completed this assessment you will be asked for your email address and name so that our team can email you the results.

Confirm and Submit