THE BURNS ANXIETY INVENTORY FOR ADULTS Name: DOB: MM slash DD slash YYYY Instructions: The following is a list of symptoms that people sometimes have. Put a (√) check in the space to the right that best describes how much that symptom or problem has bothered you during the past week. Make sure you answer all the questions. If you feel unsure about any, put down your best guess.CATEGORY 1: ANXIOUS FEELINGS1. Anxiety, nervousness, worry or fear Not at all Somewhat Moderately A lot 2. Feeling that things around you are strange, unreal, or foggy Not at all Somewhat Moderately A lot 3. Feeling detached from all or part of your body Not at all Somewhat Moderately A lot 4. Sudden unexpected panic spells Not at all Somewhat Moderately A lot 5. Apprehension or a sense of impending doom Not at all Somewhat Moderately A lot 6. Feeling tense, stressed, “uptight”, or on edge Not at all Somewhat Moderately A lot CATEGORY II: ANXIOUS THOUGHTS7. Difficulty concentrating Not at all Somewhat Moderately A lot 8. Racing thoughts or having your mind jump from one thing to the next Not at all Somewhat Moderately A lot 9. Frightening fantasies or daydreams Not at all Somewhat Moderately A lot 10. Feeling that you’re on the verge of losing control Not at all Somewhat Moderately A lot 11. Fears of cracking up or going crazy Not at all Somewhat Moderately A lot 12. Fears of fainting or passing out Not at all Somewhat Moderately A lot 13. Fears of physical illnesses or heart attacks or dying Not at all Somewhat Moderately A lot 14. Concerns about looking foolish or inadequate in front of others Not at all Somewhat Moderately A lot 15. Fears of being alone, isolated, or abandoned Not at all Somewhat Moderately A lot 16. Fears of criticism or disapproval Not at all Somewhat Moderately A lot 17. Fears that something terrible is about to happen Not at all Somewhat Moderately A lot CATEGORY III: PHYSICAL SYMPTOMS18. Skipping or racing or pounding of the heart (sometimes called “palpitations”) Not at all Somewhat Moderately A lot 19. Pain, pressure or tightness in the chest Not at all Somewhat Moderately A lot 20. Tingling or numbness in the toes or fingers Not at all Somewhat Moderately A lot 21. Butterflies or discomfort in the stomach Not at all Somewhat Moderately A lot 22. Constipation or diarrhea Not at all Somewhat Moderately A lot 23. Restlessness or jumpiness Not at all Somewhat Moderately A lot 24. Tight, tense muscles Not at all Somewhat Moderately A lot 26. A lump in the throat Not at all Somewhat Moderately A lot 27. Trembling or shaking Not at all Somewhat Moderately A lot 28. Rubbery or “jelly” legs Not at all Somewhat Moderately A lot 29. Feeling dizzy, lightheaded, or off balance Not at all Somewhat Moderately A lot 30. Choking or smothering sensations or difficulty breathing Not at all Somewhat Moderately A lot 31. Headaches or pains in the neck or back Not at all Somewhat Moderately A lot 32. Hot flashes or cold chills Not at all Somewhat Moderately A lot 33. Feeling tired, weak, or easily exhausted Not at all Somewhat Moderately A lot
