A research instrument use to determine anxiety level of subject for study

1. TEST FOR ANXIETY LEVEL
Name:__________________________ (Optional) Date:___________
Age:_________ Gender:_________
Direction:
1. Please answer each question honestly; mark check (√ ) at the chosen box that correspond to
the your rating.
2. Do not leave any item without rating; answer all of the questions under Part A, B and C.
3. You only allowed one/single rating to each item.
A rating scale of 1 – 4 that describes as follows;
1 – Very minimal or not at all
2 – Minimal
3 – Moderately so
4 – Very much so
Part A 1 2 3 4
1. Are you feeling restless right now?
2. Do you find difficulty in recognizing people that surrounds you?
3. Do you sense that you're not aware of what you're doing?
4. Are you frequently pacing in pointless direction?
5. Are you sensitive to the noise around you?
6. Was your sleep disturbed last night because you’re thinking about psyche exposure?
7. Do you have difficulty understanding with your C.I.s' or classmates' discussion?
8. Do you feel irritable now?
9. Do you feel you're having stomach upset; like feeling nauseated?
Total ___________=
Part B 1 2 3 4
1. Do you feel that your throat tighten when you speak and heighten your voice?
2. Do you have difficulty understanding with your C.I.s' or classmates' discussion?
3. Do you feel that your muscles (neck, shoulder, back or elsewhere) tighten and stiff?
4. Do you have a headache right now?
5. Is your speech changing its pace while you talk?
6. Have you observed that your mouth, lips or throat becomes dry?
7. Do you have difficulty focusing or concentrating towards your task?
8. Do you feel that your heartbeat becomes faster and stronger than usual?
9. Are you sweating than usual now?
10. Do you feel urinating more often than usual just recently?
11. Do you feel you're having stomach upset; like feeling nauseated?
Total ___________=
Part C 1 2 3 4
1. Is your focus narrowed like a tunnel becomes smaller in diameter?

2. 2. Do you have more difficulty focusing or concentrating towards your task?
3. Do you feel frightened?
4. Do you feel like crying or want to walk away from your exposure right now?
5. Do you find very difficult for you to answer this questionnaire right now?
6. Do you find yourself unable or too difficult to talk or respond when ask?
7. Do you feel like nauseating, or having stomach upset now?
8. Do you feel dizzy, shaken, cold or any of these manifestations right now?
9. Do you feel your heartbeat becomes stronger, faster and having chest tightness?
Total ___________=
Pmv-4-09