FORM 4.1. Leahy Anxiety Checklist for Patients

Patient’s Name: Today’s Date:

Place a number next to the answer that best describes how you have been feeling generally during the

past month. Use the scale below:

1 = Not at all 2 = Slightly true 3 = Somewhat true 4 = Very true

1. Feeling shaky

2. Unable to relax

3. Feeling restless

4. Get tired easily

5. Headaches

6. Shortness of breath

7. Dizzy or light-headed

8. Need to urinate frequently

9. Sweating (unrelated to heat)

10. Heart pounding

11. Heartburn or upset stomach

12. Easily irritated

13. Startled easily

14. Difficulty sleeping

15. Worried a lot

16. Hard to control worries

17. Difficulty concentrating


From Treatment Plans and Interventions for Depression and Anxiety Disorders by Robert L. Leahy and Stephen J. Holland. Copyright

2000 by Robert L. Leahy and Stephen J. Holland.