Frankford Hospitals - Center for Gynecology & Women’s Health at Frankford Hospitals

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Center for Gynecology & Women’s Health at Frankford Hospitals

Anxiety Risk Assessment

Women can answer the following questions to get a sense of their
likelihood of having or developing heart an anxiety-based condition.

Do you regularly feel nervous or fearful?	Yes	No
Do you feel restless, edgy, or irritable a lot?	Yes	No
Do you feel scared or frightened in ways that don’t feel normal to you?	Yes	No
Do you often have a sense of dread without knowing why?	Yes	No
Do you have a overwhelming feeling of being uptight and tense throughout a typical day?	Yes	No
Do you often have episodes that feel like heart palpitations or racing heartbeat, or that involve chest tightness, hot flashes or chills, or cold, clammy hands?	Yes	No
Do you have difficulty concentrating?	Yes	No
Are you jumpy, or easily startled or alarmed?	Yes	No
Do you feel self-conscious or insecure most of the time?	Yes	No
Do you feel overly vigilant or wary most of the time?	Yes	No
Do you have trouble falling or staying asleep?	Yes	No
Do things that seem like they should be normal activities of life bring on a level of anxiousness that causes you to avoid them?	Yes	No
Have worrisome feelings caused you to stop activities that you were previously able to include in your life?	Yes	No
Have you ever had a spell that developed quickly in which you felt immobilized, out of breath, panicked, or out of control?	Yes	No
Do you feel driven or forced by yourself to do certain activities over and over again?	Yes	No
Have you experienced stressful life events recently or major life challenges such as death of a loved on, divorce, loss of job, or illness?	Yes	No
Do you have nagging physical symptoms that don’t seem to go away or that you don’t find a reason for (including headaches, muscle tension, dizziness, frequent urination, or nausea or other digestive complaints)?	Yes	No

The more often you answered “Yes” to the above questions, the greater your risk for developing or already having an anxiety-based condition. If you answered “Yes” to questions above, consider discussing anxiety with one of our Women’s Center healthcare providers.

Print this page and bring it with you, filled out, to your appointment.

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