This free survey is powered by
  1. Surveys
  2. 2013
  3. November
  4. A
  5. Anxiety
0%
Exit Survey
 
 
Are you male or female?
 
Male
 
Female
 
 
 
Have you been diagnosed with anxiety?
 
Yes
 
No
 
 
 
When does anxiety occur most?
 
Morning
 
Afternoon
 
Night
 
 
 
Do you have any support networks to attend? E.g. counseling etc. If yes provide answer below.
   
 
 
 
How often do you feel anxious? Hardly 1 2 3 4 5 Always
 
1
 
2
 
3
 
4
 
5
 
 
Rate your symptoms from 1-5. Rare 1 2 3 4 5 Extreme
1 2 3 4 5
 
 
 
 
Does anxiety interfere with attending social events e.g. shopping, occasions? If yes please specify below.
   
 
 
 
Do you take medication for anxiety?
 
Yes
 
No
 
 
 
Do you find these treatments are supporting your anxiety?
 
Yes
 
No
 
 
 
Any further comments?