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Name: Age: Sex: Housing Assignment: Previous Diagnoses: Current/Past Medical Conditions: Medication: Emergency Contact: Can we share information with your emergency contact: Are you currently suffering from any of the following symptoms, and how often do you suffer from them? ( Usually, Often, Sometimes, Rarely, Never) Pounding heart Sweating: Trembling or shaking Shortness of breath Afraid or scared Chest pain or discomfort Nausea or abdominal distress Feeling dizzy or unsteady Fear of losing control or going crazy Numbness or tingling sensations Chills or hot flashes Fear of dying Constant or persistent worry Feeling of choking Unable to relax Feeling of being unreal Nervous Feeling shaky or wobbly Irritable or difficulty sleeping Trembling hands Avoid situations because of anxiety Feeling lightheaded or faint Please indicate whether or not these symptoms: Interfere with work: Affect my relationships with friends or family: Have led to using alcohol to get by: Have led to using drugs: Over the last two weeks, have you noticed the following: (Use the number that best describes you.) 0 - NOT AT ALL 1 - RARELY 2 - SOMETIMES 3 - OFTEN 4 - MOST OF THE TIME I feel sad, down in the dumps or unhappy: I can’t concentrate or focus: Nothing seems to give me much pleasure: I feel tired; have no energy: I have had thoughts of suicide: Changes in sleeping patterns: (more, less) Changes in appetite: (more, less) I worry about dying or losing control: I am nervous or shaky in social situations: I have nightmares or flashbacks: I am jumpy or feel startled easily: I avoid places that strongly remind me of a bad experience: I can’t get certain thoughts out of my mind: I feel I must repeat certain acts or rituals: I feel the need to check and recheck things: