For each question below please rate from feeling on a five point scale

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* 1. First Name

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* 2. Last Name

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* 3. email address

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* 4. Have you been previously diagnosed by a physician to have  Anxiety

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* 5. If the answer to question 3 was yes, what type of anxiety do you suffer from?

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* 6. Please list any medications you are currently taking for anxiety

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* 7. I feel more nervous and anxious than usual

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* 8. I feel afraid for no reason at all

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* 9. I get upset easily or feel panicky

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* 10. I feel like I am falling apart and going to pieces

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* 11. I feel that everything is all right and nothing bad will happen

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* 12. My arms and legs shake and tremble

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* 13. I am bothered by headaches, neck and back pains

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* 14. I feel weak and get tired easily

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* 15. I feel calm and can sit still easily

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* 16. I can feel my heart beating fast

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* 17. I am bothered by dizzy spells

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* 18. I have fainting spells or feel faint

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* 19. I can breathe in and out easily

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* 20. I get feelings of numbness and tingling in my fingers and toes

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* 21. I am bothered by stomachaches or indigestion

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* 22. I have to empty my bladder often

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* 23. My hands are usually dry and warm

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* 24. My face gets hot and blushes

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* 25. I fall asleep easily and get a good night's rest

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* 26. I have nightmares

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* 27. Any additional symptoms describing anxiety?  Please include a rating of 0-4 with 0 meaning not at all, 4 meaning severe