Beck Anxiety Inventory (BAI)

The screens you are filling out will be billed to your insurance. We recommend these screens as they follow the best practice as set forth by the American Academy of Pediatrics.
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 selecting the item in the corresponding space in the
column next to each symptom.
Name Name * First Last
DOB DOB * / MM / DD YYYY
Phone Phone * - ### - ### ####
Email *

Please answer the following questions:
Please answer the following questions:	Not at all	Mildly - it didn’t bother me much	Moderately – it wasn’t pleasant at times	Severely – it bothered me a lot
Numbness or tingling	Numbness or tinglingNot at all	Numbness or tinglingMildly - it didn’t bother me much	Numbness or tingling	Numbness or tinglingSeverely – it bothered me a lot
Feeling hot	Feeling hotNot at all	Feeling hotMildly - it didn’t bother me much	Feeling hot	Feeling hotSeverely – it bothered me a lot
Wobbliness in legs	Wobbliness in legsNot at all	Wobbliness in legsMildly - it didn’t bother me much	Wobbliness in legs	Wobbliness in legsSeverely – it bothered me a lot
Unable to relax	Unable to relaxNot at all	Unable to relaxMildly - it didn’t bother me much	Unable to relax	Unable to relaxSeverely – it bothered me a lot
Fear of worst happening	Fear of worst happeningNot at all	Fear of worst happeningMildly - it didn’t bother me much	Fear of worst happening	Fear of worst happeningSeverely – it bothered me a lot
Dizzy or lightheaded	Dizzy or lightheadedNot at all	Dizzy or lightheadedMildly - it didn’t bother me much	Dizzy or lightheaded	Dizzy or lightheadedSeverely – it bothered me a lot
Heart pounding / racing	Heart pounding / racingNot at all	Heart pounding / racingMildly - it didn’t bother me much	Heart pounding / racing	Heart pounding / racingSeverely – it bothered me a lot
Unsteady	UnsteadyNot at all	UnsteadyMildly - it didn’t bother me much	Unsteady	UnsteadySeverely – it bothered me a lot
Terrified or afraid	Terrified or afraidNot at all	Terrified or afraidMildly - it didn’t bother me much	Terrified or afraid	Terrified or afraidSeverely – it bothered me a lot
Nervous	NervousNot at all	NervousMildly - it didn’t bother me much	Nervous	NervousSeverely – it bothered me a lot
Feeling of choking	Feeling of chokingNot at all	Feeling of chokingMildly - it didn’t bother me much	Feeling of choking	Feeling of chokingSeverely – it bothered me a lot
Hands trembling	Hands tremblingNot at all	Hands tremblingMildly - it didn’t bother me much	Hands trembling	Hands tremblingSeverely – it bothered me a lot
Shaky / unsteady	Shaky / unsteadyNot at all	Shaky / unsteadyMildly - it didn’t bother me much	Shaky / unsteady	Shaky / unsteadySeverely – it bothered me a lot
Fear of losing control	Fear of losing controlNot at all	Fear of losing controlMildly - it didn’t bother me much	Fear of losing control	Fear of losing controlSeverely – it bothered me a lot
Difficulty in breathing	Difficulty in breathingNot at all	Difficulty in breathingMildly - it didn’t bother me much	Difficulty in breathing	Difficulty in breathingSeverely – it bothered me a lot
Fear of dying	Fear of dyingNot at all	Fear of dyingMildly - it didn’t bother me much	Fear of dying	Fear of dyingSeverely – it bothered me a lot
Scared	ScaredNot at all	ScaredMildly - it didn’t bother me much	Scared	ScaredSeverely – it bothered me a lot
Indigestion	IndigestionNot at all	IndigestionMildly - it didn’t bother me much	Indigestion	IndigestionSeverely – it bothered me a lot
Faint / lightheaded	Faint / lightheadedNot at all	Faint / lightheadedMildly - it didn’t bother me much	Faint / lightheaded	Faint / lightheadedSeverely – it bothered me a lot
Face flushed	Face flushedNot at all	Face flushedMildly - it didn’t bother me much	Face flushed	Face flushedSeverely – it bothered me a lot
Hot / cold sweats	Hot / cold sweatsNot at all	Hot / cold sweatsMildly - it didn’t bother me much	Hot / cold sweats	Hot / cold sweatsSeverely – it bothered me a lot

Beck Anxiety Inventory (BAI)

Beck Anxiety Inventory (BAI)

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 selecting the item in the corresponding space in the column next to each symptom.

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 selecting the item in the corresponding space in the
column next to each symptom.