specializing in MIND-BODY CONNECTION AND CHAKRA BALANCING

GROSSMAN

PSYCHOLOGICAL

SERVICES


Below is a list of phrases that describe certain feeling that people have. Rate the patients by finding the answer which best describes the extent to which he/she has these conditions. Select one of the five responses for each of the fourteen questions.


0 = Not present                          1 = Mild                         2 = Moderate                          3 = Severe                          4 = Very Severe

IF THERAPY IS NOT RIGHT FOR YOU, TAKE A LOOK AT WHAT COACHING CAN OFFER.

1. Anxious mood: Worries, anticipation of the worst, fearful anticipation, irritability.                                          0     1     2     3     4
2. Tension: Feelings of tension, fatigability, startle response, moved to tears easily, trembling,

    feelings of restlessness, inability to relax.                                                                                                           0     1     2     3     4
3. Fears: Of dark, of strangers, of being left alone, of animals, of traffic, of crowds.                                              0     1     2     3     4

4. Insomnia: Difficulty in falling asleep, broken sleep, unsatisfying sleep and fatigue
    on waking, dreams, nightmares, night terrors.                                                                                                    0     1     2     3     4
5. Intellectual: Difficulty in concentration, poor memory.                                                                                       0     1     2     3     4
6. Depressed mood: Loss of interest, lack of pleasure in hobbies, depression, early waking,
    diurnal swing.                                                                                                                                                       0     1     2     3     4

7. Somatic (muscular): Pains and aches, twitching, stiffness, myoclonic jerks, grinding of
    teeth, unsteady voice, increased muscular tone.                                                                                                0     1     2     3     4

8. Somatic (sensory): Tinnitus, blurring of vision, hot and cold flushes, feelings of weakness,
    pricking sensation.                                                                                                                                               0     1     2     3     4
9. Cardiovascular symptoms: Tachycardia, palpitations, pain in chest, throbbing of vessels, fainting
    feelings, missing beat.                                                                                                                                          0     1     2     3     4
10. Respiratory symptoms: Pressure or constriction in chest, choking feelings, sighing, dyspnea.                          0     1     2     3     4
11. Gastrointestinal symptoms: Difficulty in swallowing, wind abdominal pain, burning sensations,
      abdominal fullness, nausea, vomiting, borborygmi, looseness of bowels, loss of weight, constipation.             0     1     2     3     4
12. Genitourinary symptoms: Frequency of micturition, urgency of micturition, amenorrhea,
     menorrhagia, development of frigidity, premature ejaculation, loss of libido, impotence.                                 0     1     2     3     4
13. Autonomic symptoms: Dry mouth, flushing, pallor, tendency to sweat, giddiness, tension
     headache, raising of hair.                                                                                                                                     0     1     2     3     4

14. Behavior at interview:  Fidgeting, restlessness or pacing, tremor of hands, furrowed brow,
     strained face, sighing or rapid respiration, facial pallor, swallowing, etc.                                                            0     1     2     3     4


SCORING

Total Score: (sum up all 14 items) = ______________

<17 = Mild                                17-24 = Mild to Moderate                          25-30  =  Moderate to Severe*


*Therapy is recommended to decreased distress and increase functioning for scores in the moderate to severe range.

HAMILTON ANXIETY RATING SCALE (HAM-A)