We Accept The Canadian Dental Care Plan (CDCP). Schedule Your Appointment Today!

Beck Anxiety Inventory

Patient's Legal Name:(Required)
Date of Birth:(Required)

Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much you have been bothered by that symptom during the past month, including today, by clicking the number in the corresponding space in the column next to each symptom.
0. Not At All
1. Mildly but it didn’t bother me much.
2. Moderately - it wasn’t pleasant at times
3. Severely - it bothered me a lot
Numbness or tingling
Feeling hot
Wobbliness in legs
Unable to relax
Fear of worst happening
Dizzy or lightheaded
Heart pounding/racing
Unsteady
Terrified or afraid
Nervous
Feeling of choking
Hands trembling
Shaky / unsteady
Fear of losing control
Difficulty in breathing
Fear of dying
Scared
Indigestion
Faint / lightheaded
Face flushed
Hot / cold sweats