Hamilton Anxiety Scale printable pdf download

Hamilton Anxiety Scale

Name:

Date:

DOB:

Height:

Weight:

Health Care Provider:

Phone:

Questions

Put a check mark in the box that BEST describes how you have felt in the last 6 months

Symptoms

Not

Very

Mild Moderate Severe

Present

Severe

Anxiety

Worry, irritability, fearful anticipation

Tension

Restlessness, stress, inability to relax

Fear

Irrational phobia, excessive worry

Insomnia

Fatigue, inability to sleep, nightmares, night terrors

Intellectual Symptoms

Poor concentration, memory impairment

Depressed Mood

Decreased interest in activities, diurnal swing, early waking

Muscular Symptoms

Aches and pains, stiffness, twitching, teeth grinding

Sensory Symptoms

Tinnitus, blurred vision, hot/cold flushes, weakness

Cardiovascular Symptoms

Tachycardia, palpitations, chest pain, fainting, throbbing

Respiratory Symptoms

Chest pressure/constrictions, choking, sighing, dyspnea

Gastrointestinal Symptoms

Swallowing difficulties, abdominal pain, nausea, weight loss

Genitourinary Symptoms

Frequency/urgency of micturition, amenorrhea, impotence

Autonomic Symptoms

Dry mouth, flushing, pallor, sweating, giddiness, headache

Behavior at Interview

Fidgeting, restlessness, tremors, sighing, pallor, straining

Hamilton Anxiety Scale