BAI Below is a list of common symptoms of anxiety. Please read each item in the list carefully. Indicate how much you have been bothered by that symptom during the past month, including today. Your results will only be visible to the doctor/clinician involved in your care, and will not be shared with any external parties. Name Email address Date of birth (for identity verification) 1. Numbness or tingling Not at all Mildly, but it didn’t bother me much Moderately, it wasn’t pleasant at times Severely, it bothered me a lot None 2. Feeling Hot Not at all Mildly, but it didn’t bother me much Moderately, it wasn’t pleasant at times Severely, it bothered me a lot None 3. Wobbliness in legs Not at all Mildly, but it didn’t bother me much Moderately, it wasn’t pleasant at times Severely, it bothered me a lot None 4. Unable to relax Not at all Mildly, but it didn’t bother me much Moderately, it wasn’t pleasant at times Severely, it bothered me a lot None 5. Fear of the worst happening Not at all Mildly, but it didn’t bother me much Moderately, it wasn’t pleasant at times Severely, it bothered me a lot None 6. Dizzy or lightheaded Not at all Mildly, but it didn’t bother me much Moderately, it wasn’t pleasant at times Severely, it bothered me a lot None 7. Heart pounding/racing Not at all Mildly, but it didn’t bother me much Moderately, it wasn’t pleasant at times Severely, it bothered me a lot None 8. Feeling unsteady Not at all Mildly, but it didn’t bother me much Moderately, it wasn’t pleasant at times Severely, it bothered me a lot None 9. Terrified or afraid Not at all Mildly, but it didn’t bother me much Moderately, it wasn’t pleasant at times Severely, it bothered me a lot None 10. Feeling nervous Not at all Mildly, but it didn’t bother me much Moderately, it wasn’t pleasant at times Severely, it bothered me a lot None 11. Feeling of choking Not at all Mildly, but it didn’t bother me much Moderately, it wasn’t pleasant at times Severely, it bothered me a lot None 12. Hands trembling Not at all Mildly, but it didn’t bother me much Moderately, it wasn’t pleasant at times Severely, it bothered me a lot None 13. Feeling unsteady or shaky Not at all Mildly, but it didn’t bother me much Moderately, it wasn’t pleasant at times Severely, it bothered me a lot None 14. Fear of losing control Not at all Mildly, but it didn’t bother me much Moderately, it wasn’t pleasant at times Severely, it bothered me a lot None 15. Difficulties breathing Not at all Mildly, but it didn’t bother me much Moderately, it wasn’t pleasant at times Severely, it bothered me a lot None 16. Fear of dying Not at all Mildly, but it didn’t bother me much Moderately, it wasn’t pleasant at times Severely, it bothered me a lot None 17. Feeling scared Not at all Mildly, but it didn’t bother me much Moderately, it wasn’t pleasant at times Severely, it bothered me a lot None 18. Indigestion Not at all Mildly, but it didn’t bother me much Moderately, it wasn’t pleasant at times Severely, it bothered me a lot None Thank you for filling up this form. Your results will be sent directly to your doctor. Time's up
