1. Do you avoid certain situations because you are afraid or embarrassed to be negatively evaluated by other people?

No Yes

2. Do you tend to focus on upsetting situations or events happening in my life?

No Yes

3. Do you worry excessively about your job, school performance, home life, your health, or finances?

No Yes

4. Are you easily alarmed, frightened, or surprised?

No Yes

5. Do you have trouble falling asleep or staying asleep?

No Yes

6. Do you often think about how unsatisfied you are with your life?

No Yes

7. Do you ever find yourself avoiding certain situations or places that increase your anxiety?

No Yes

8. Do you have difficulty concentrating or making decisions when dealing with personal or work issues?

No Yes

9. Do you suffer from indigestion problems (e.g. peptic ulcer, acid reflux, constipation, etc.)?

No Yes

10. Are you afraid of crowds, being left alone, the dark, of strangers, or of traffic?

No Yes

11. Do you think a lot about why you do the things you do?

No Yes

12. Do you get numbness and/or tingling feeling in your extremities (i.e. hands, feet, etc.)?

No Yes

13. Do you sometimes have difficulty concentrating or remembering things?

No Yes

14. Have you recently loss interest in activities that you normally enjoyed in the past?

No Yes

15. Do you experience palpitations, heart pounding, or accelerated heart rate at times?

No Yes

16. Do you often have nightmares?

No Yes

17. Do you feel tense or extremely jumpy?

No Yes

18. When speaking in front of a large crowd, do you experience sweaty palms, being tongue-tied or loss of words, extreme nervousness, confusion, or fearfulness?

No Yes

19. Have you experienced a feeling of nervousness or a feeling of uneasiness more than once in the past month?

No Yes

20. Do you occasionally feel that you are losing control?

No Yes

21. DISCLAIMER

This Site Does Not Provide Medical Advice.

The contents of the Brookhaven Retreat, LLC (“Brookhaven”) website ( the "Content") are for informational purposes only. The Content is not intended to be a substitute for professional psychological psychiatric or medical advice, diagnosis, or treatment. Consult with your physician, psychiatrist, psychologist, or other qualified health provider without delay to gain more information regarding your specific medical and/or psychological condition.

If you think you may have a medical emergency, call your doctor or 911 immediately. Brookhaven does not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned on the Site. Reliance on any information provided by Brookhaven, Brookhaven employees, others appearing on the Site at the invitation of Brookhaven, or other visitors to the Site is solely at your own risk.

Please read and accept the terms.

I understand and agree.

User Details

Name:
Email: