Pre-Course Anxiety Questionnaire Name or Initials Email Over the last 2 weeks, how often have you been bothered by the following problems? 1. Feeling nervous, anxious or on edge Please Select: 0 - Not at all 1 - Several Days 2 - More than half the days 3 - Nearly Every Day 2. Not being able to stop or control worrying Please Select: 0 - Not at all 1 - Several Days 2 - More than half the days 3 - Nearly Every Day 3. Worrying too much about different things Please Select: 0 - Not at all 1 - Several Days 2 - More than half the days 3 - Nearly Every Day 4. Having trouble relaxing Please Select: 0 - Not at all 1 - Several Days 2 - More than half the days 3 - Nearly Every Day 5. Being so restless that it is hard to sit still Please Select: 0 - Not at all 1 - Several Days 2 - More than half the days 3 - Nearly Every Day 6. Becoming easily annoyed or irritable Please Select: 0 - Not at all 1 - Several Days 2 - More than half the days 3 - Nearly Every Day 7. Feeling afraid, as if something awful might happen Please Select: 0 - Not at all 1 - Several Days 2 - More than half the days 3 - Nearly Every Day Please complete the following 3 additional questions. I will compare your answers to those you provide on completion of the course. This will help me to review how helpful it has been for you. 1. Please provide a rating for the level of your anxiety over the last week Please Select 1 - None at all 2 3 4 5 6 7 8 9 10 - The worst it’s ever been 2. How much of a negative impact has your anxiety had on your life over the last week? Please Select 1 - No impact 2 3 4 5 6 7 8 9 10 - stopped me doing anything I want to do 3. Please identify 3 goals for what you would like to achieve from this course: E.g. to have fewer panic attacks I consent for this to be sent confidentially to percuropsychology.co.uk Send
