REFRAME Anxiety Assessment The purpose of this form is to gather a brief picture of your experience; how you are thinking about it and how you are responding. Please fill out the contact information. [form] Name[text,r_name,30] Email [text,r_email,30] FOR THE FOLLOWING ITEMS, PLEASE RATE EACH ONE IN TERMS OF HOW OFTEN (frequently) they occur for you. I FEEL ANXIOUS (fearful) WHEN I am facing a threat [list,I am facing a threat][option,choose,frequency?,selected][option,0,0 Not at all][option,1,1 Sometimes][option,2,2 Frequently][option,3,3 Most of the time][/list] I am facing a danger [list,I am facing a danger][option,choose,frequency?,selected][option,0,0 Not at all][option,1,1 Sometimes][option,2,2 Frequently][option,3,3 Most of the time][/list] I am facing a challenge [list,I am facing a challenge][option,choose,frequency?,selected][option,0,0 Not at all][option,1,1 Sometimes][option,2,2 Frequently][option,3,3 Most of the time][/list] OTHER ANXIETY SITUATIONS? [text,other triggers,80] I FEEL ANXIETY to this Level [list,My General assessment of the Impact is] [option,0,Choose level of ANXIETY IMPACT] [option,1 The absence of any distress,1 The absence of any distress. Feeling calm and totally relaxed] [option,2 Neutral feeling or just OK,2 Neutral feeling or just OK, not as relaxed as could be] [option,3 Increased discomfort,3 Increased discomfort, unpleasant, but in control] [option,4 Noticeable discomfort or distress,4 Noticeable discomfort or distress, perhaps agitation, but tolerable] [option,5 Discomfort is very uncomfortable,5 Discomfort is very uncomfortable, but I can stand it.] [option,6 Discomfort worsens and affects my life,6 Discomfort worsens and affects my life] [option,7 Discomfort is severe emotional pain interferes,7 Discomfort is severe and emotional pain interferes with my life.] [option,8 Discomfort increases in thoughts constantly,8 Discomfort increases and it is in my thoughts constantly] [option,9 Nearly intolerable,9 Discomfort is nearly intolerable] [option,10 discomfort extreme worst imaginable,10 Discomfort is extreme and the worst imaginable. I feel panicky and overwhelmed.] [/list] HOW I RESPOND WHEN I FEEL ANXIOUS IS I ward off the threat [event] with ritual, superstition etc. [list,I ward off the threat [event] with ritual, superstition etc.][option,choose,frequency?,selected][option,0,0 Not at all][option,1,1 Sometimes][option,2,2 Frequently][option,3,3 Most of the time][/list] I tranquilise my feelings with medication or substances. [list,I tranquilise my feelings with medication or substances.][option,choose,frequency?,selected][option,0,0 Not at all][option,1,1 Sometimes][option,2,2 Frequently][option,3,3 Most of the time][/list] I seek reassurance from others [list,I seek reassurance from others][option,choose,frequency?,selected][option,0,0 Not at all][option,1,1 Sometimes][option,2,2 Frequently][option,3,3 Most of the time][/list] I am taking medication prescribed by a medical professional [list,I am taking medication prescribed by a medical professional][option,choose,frequency?,selected][option,0,0 Not at all][option,1,1 Sometimes][option,2,2 Frequently][option,3,3 Most of the time][/list] OTHER ANXIETY RESPONSES? [text,other responses,80] BECAUSE I overestimate the negative features of the event [list,I overestimate the negative features of the (event)][option,choose,frequency?,selected][option,0,0 Not at all][option,1,1 Sometimes][option,2,2 Frequently][option,3,3 Most of the time][/list] I underestimate my ability to cope with the threat [list,I underestimate my ability to cope with the threat][option,choose,frequency?,selected][option,0,0 Not at all][option,1,1 Sometimes][option,2,2 Frequently][option,3,3 Most of the time][/list] I create an even more negative threat in my mind [list,I create an even more negative threat in my mind][option,choose,frequency?,selected][option,0,0 Not at all][option,1,1 Sometimes][option,2,2 Frequently][option,3,3 Most of the time][/list] I have more task irrelevant thoughts than mere concern [list,I have more task irrelevant thoughts than mere concern][option,choose,frequency?,selected][option,0,0 Not at all][option,1,1 Sometimes][option,2,2 Frequently][option,3,3 Most of the time][/list] I withdraw mentally from the event [list,I withdraw mentally from the (event)][option,choose,frequency?,selected][option,0,0 Not at all][option,1,1 Sometimes][option,2,2 Frequently][option,3,3 Most of the time][/list] I withdraw physically from the (event) [list,I withdraw physically from the event ][option,choose,frequency?,selected][option,0,0 Not at all][option,1,1 Sometimes][option,2,2 Frequently][option,3,3 Most of the time][/list] OTHER ANXIETY Thoughts [text,other thoughts or self talk,80] IF any of the following statements are similar to your because-thoughts with this issue, please check them in the box beside. [checkbox,I must do well or very well]I MUST do well or very well! [checkbox, I am a BAD or WORTHLESS PERSON when I act weakly, or stupidly]I am a BAD or WORTHLESS PERSON when I act weakly, or stupidly. [checkbox,I MUST be approved, acknowledged or accepted by people I find important to me]I MUST be approved, acknowledged or accepted by people I find important to me. [checkbox,People MUST treat me fairly and give me what I NEED]People MUST treat me fairly and give me what I NEED. [checkbox,People MUST live up to my expectations or it is TERRIBLE ... awful]People MUST live up to my expectations or it is TERRIBLE (awful...) [checkbox,I CAN'T STAND really bad things or very difficult people]I CAN'T STAND really bad things or very difficult people! [checkbox,MUST have few major hassles or troubles]My work (task, job...) MUST have few major hassles or troubles. [checkbox,It's AWFUL or HORRIBLE when major (important...) things don't go my way]It's AWFUL or HORRIBLE when major (important...) things don't go my way [checkbox,I CAN'T STAND IT when work (tasks, situation...) is really unfair]I CAN'T STAND IT when work (tasks, situation...) is really unfair. [checkbox,I NEED a good deal of gratification (satisfaction...) and HAVE to feel miserable (upset, disturbed) when I don't get it.]I NEED a good deal of gratification (satisfaction...) and HAVE to feel miserable (upset, disturbed) when I don't get it. [checkbox,I must not suffer more discomfort than I feel I can bear]I MUST NOT experience more discomfort physically or emotionally than I feel I can bear Please share with me anything else you feel I need to know to understand you and your experience of Anger? [textarea,comments,3,70,Write in here...] ========================================================== Please share with me anything else you feel I need to know to understand you and your experience of Anger? [textarea,comments,3,70,Write in here...] [checkbox,send copy,checked] SEND ME A COPY PLEASE [submit,SEND this Entry][reset,Start Over again] [/form]